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THE    RULES 


OF 


ASEPTIC  AND  ANTISEPTIC 
SUHaERY 


A  PRACTICAL  TREATISE  FOR  THE  USE  OF  STUDENTS 
AND  THE  GENERAL  PRACTITIONER 


BY 

AEPAD   G.   GERSTEE,   M.  D. 


PROFESSOR  OF  SURGERY  AT  THE  NEW  YORK   POLYCLINIC.;  VISITING  SURGEON  TO  MOUNT  SINAI  HOSPITAL 
AND    THE   GERMAN   HOSPITAL,    NEW  YORK 


ILLUSTRATED   WITH  TWO  HUNDRED  AND  FORTY-EIGHT  ENGRAVINGS 
AND  THREE  CHROMO-LITHOGRAPHIC  PLATES 


SECOND    EDITION. 


NEW  YORK 
D.     APPLETON    AND    COMPANY 

1888 


/rtf 


Copyright,  1888. 

By  d.  appleton  and  company. 


2c^ 


PREFACE 


The  object  of  this  volume  is  a  systematic  yet  practical  presentation 
of  the  Listerian  principle  that  has  revolutionized  surgery  within  the  last 
fifteen  years.  Its  adoption  has  wrought  so  many  incisive  changes  in 
practice,  has  shifted  the  surgeon's  standpoint  regarding  all  the  important 
disciplines  of  the  art  in  such  a  radical  manner,  that  most  English  text- 
books of  surgery,  even  those  recently  pubhshed,  have  become  partly  or 
entirely  inadequate  to  the  wants  of  the  modern  physician. 

To  a  large  number  of  medical  men  the  aseptic  and  antiseptic  methods 
present  an  incongruous  chaos  of  seemingly  contradictory  and  often  in- 
comprehensible detail,  arbitrary  and  varying,  according  to  the  predilections 
or  whims  of  this  or  that  teacher. 

Yet  the  principle  involved  is  based  on  the  correct  observation  of  a 
common  biological  process — namely,  that  of  the  decomposition  of  organic 
substances.  The  well-known  methods  employed  since  the  earliest  dawn 
of  civihzation  for  the  preservation  of  organic,  especially  animal,  sub- 
stances, are  based  upon  the  empirical  yet  correct  appreciation  of  the 
causes  of  putrefaction,  and  the  practical  adaptation  of  these  methods  to 
the  healing  of  operative  or  accidental  wounds  contains  the  whole  essence 
of  the  new  surgery. 

Evils  that  former  generations  of  surgeons  deplored,  but  could  not 
effectually  combat,  such  as  septicaemia,  pysemia,  hospital  gangrene,  and 
erysipelas,  have  been  much  abated,  as  a  direct  consequence  of  a  clear 
understanding  of  their  essential  nature  and  causation. 

Prevention  has  become  the  watchword  of  modern  practice,  and  it  can 
be  said  that,  by  the  successful  employment  of  the  preventive  methods  of 
the  present  day,  surgery  has  become  a  conservative  branch  of  the  heal- 
ing art. 


iv  PREFACE. 

The  elimination  of  the  accidental  disturbances  of  repair  caused  by 
wound  infection  has  depressed  the  percentage  of  mortality  following 
am]iutation  of  the  extremities  from  an  average  of  thirty-five  per  cent  to 
al)out  fifteen  per  cent. 

The  dread  of  undertaking  and  submitting  to  a  surgical  operation  has 
greatly  diminished,  and  timely — that  is,  early — surgical  interference  has 
become  more  and  more  frequent,  to  the  great  advantage  of  both  patient 
and  physician. 

As  a  direct  consequence  of  the  implied  obligation  of  rendering  timely 
aid  where  possible,  a  laudable  eagerness  for  an  early  diagnosis  is  developed, 
and,  there  being  so  much  to  be  gained  by  diagnostic  knowledge,  thorough 
and  practical  study  of  the  morbid  processes  requiring  surgical  aid  has 
been  greatly  stimulated. 

The  fear  of  suppuration  with  its  dreadful  consequences  does  not  stay 
now  the  hand  of  the  surgeon  as  of  old,  when  an  operation  was  always 
considered  a  forlorn  hope  and  a  last  resort.  Strangulated  hernise,  for 
instance,  are  not  allowed  to  gangrene  as  often  as  formerly,  and  herniotomy 
is  readily  resorted  to,  as  it  is  well  known  that  the  dangers  of  an  aseptic 
herniotomy  done  on  a  healthy  gut  are  diminutive  in  comparison  to  the 
certain  and  enormous  danger  of  strangulation  itself. 

By  the  conviction  that  a  fault  of  omission  may  be  followed  by  irre- 
mediable mischief,  the  sense  of  responsibility  is  stirred  up  to  vigilance, 
which  again  breeds  self-reliance  and  firmness  of  purpose  in  advising  and 
carrying  out  incisive  measures,  made  clearly  necessary  by  a  well-recognized 
danger  to  life  or  limb.  And  an  additional  degree  of  responsibility  is 
imposed  by  the  very  safety  of  aseptic  operations. 

It  can  not  now  be  successfully  denied  that  the  su7'geon''s  acts  deter- 
mine the  fate  of  a  fresh  wound,  and  that  its  infection  nnd  sujpjpiiratioih 
a/re  due  to  his  technical  faults  of  omission  or  commission. 

The  piinciple  underlying  antiseptic  surgery  has  ceased  to  be  the 
subject  of  serious  controversy.  The  author  does  not  undertake  to  prove 
each  of  his  statements  to  the  satisfaction  of  those  who  look  but  see  not. 
His  object  is  instruction  rather  than  controversy.  Every  one  will  have 
to  pass  his  period  of  apprenticeship  with  its  blunders  and  lessons.  But 
he  who  becomes  a  master,  to  whom  the  primary  healing  of  a  fresh 
wound  remains  not  a  curiosity  but  becomes  a  matter  of  course,  will  not 
doubt  the  great  change  that  has  come  over  surgery. 


PREFACE.  y 

The  purely  practical  tendency  of  the  work  made  a  rather  free  ar- 
rangement of  the  several  parts  of  the  subject-matter  a  necessity,  or  at 
least  a  convenience;  yet  a  sufficiency  of  systematic  order  was  preserved 
to  give  the  collection  of  papers  the  character  of  a  well-rounded,  organic 
whole. 

The  author  begs  to  state  explicitly  that  completeness — that  is,  the 
inclusion  of  all  the  disciplines  of  surgery — was  not  aimed  at,  else  a  com- 
plete text-book  of  surgery  would  have  resulted.  The  leading  idea,  trace- 
able through  all  the  matter  contained  in  the  book,  is  to  illustrate  the 
incisive  practical  changes  that  the  adoption  of  aseptic  and  antiseptic  meth- 
ods has  wrought  in  surgical  therapy.  Hereby  the  changes  in  wound 
treatment  are  meant,  as  well  as  the  notable  extension  of  active  surgery 
into  fields  formerly  considered  a  noli  me  tangere. 

As  a  consequence  of  the  stupendous  growth  of  operative  surgery  within 
the  last  decade,  a  fruitful  development  of  operative  technique  is  to  be 
noted  also.  -In  accordance  with  the  desire  of  the  author  to  present  to  the 
profession  a  vivid  and  true  picture  of  contemporaneous  methods,  the  terms 
used  as  the  title  of  this  work  should  be  accepted  in  their  widest  signifi- 
cance. 

Confinement  to  the  meager  details  of  those  manipulations  which, 
strictly  speaking,  constitute  aseptic  and  antiseptic  measures,  would  have 
yielded  an  inadequate  and  tedious  compilation.  On  the  other  hand,  it  is 
hoped  that  the  pathological  and  technical  diversions,  introduced  for  the 
sake  of  laying  a  rational  foundation  to  the  principles  composing  the 
essence  of  antijpo/rasitic  surgery,  may  be  admitted  as  germane  to  the 
subject. 

The  methods  of  wound  treatment  herein  explained  are  to  a  certain 
extent  still  undergoing  changes,  hence  should  not  be  accepted  as  final. 
Yet  it  is  undeniable  that,  as  the  clearness  of  the  comprehension  of  the 
simple  principle  of  asepticism  applied  to  wound  treatment  has  advanced, 
so  the  frequent  changes  and  bewildering  vacillation  characteristic  of  the 
experimental  stage  of  the  new  discipline  have  naturally  given  way  to 
steadier  methods.  At  present,  changes  are  not  so  frequent  as  formerly, 
yet  progress,  especially  the  conquest  of  new  fields  for  the  legitimate  prac- 
tice of  active  surgery,  is  not  at  a  standstill. 

The  author  is  well  aware  that  the  practical  directions  recommended 
by  him  are  not  the  only  ones  that  lead  to  success.     Tet,  in  the  main,  he 


vi  PREFACE. 

lias  refrained  from  quoting  other  authorities.  As  reasons  for  this  may  be 
adduced,  fii-st,  the  disinclination  to  write  a  bulky  text-book,  and,  further, 
the  knowledge  that  the  interest  of  the  reader  is  proportionate  to  the 
du'ectness  and  immediate  character  of  the  facts  and  thoughts  contained 
in  the  work  under  perusal. 

As  fai'  as  possible,  all  important  statements  will  be  fonnd  borne  out  by 
illustrative  examples  taken  from  the  author's  j)ersonal  experience. 

The  author  is  much  indebted  to  the  gentlemen  composing  the  house 
staffs  of  the  German  and  Mount  Sinai  Hospitals  for  the  ready  kindness 
and  courtesy  with  which  their  help  was  proffered  in  tracing  and  extract- 
ing histories  of  cases,  and  in  making  the  very  numerous  photographic 
plates  that  form  the  bulk  of  the  illustrations. 

Great  technical  difficulties,  inherent  to  the  unfavorable  season,  the 
small  space  and  inadequate  lighting  of  the  operating-rooms  of  the  men- 
tioned hospitals,  had  to  be  overcome  in  exposing  the  sensitive  plates. 
The  matter  was  rendered  still  more  difficult  by  the  circumstance  that 
operating  and  photographing  were  done  by  one  and  the  same  set  of  per- 
sons, and  that  the  welfare  and  interests  of  the  patients  themselves  had 
constantly  to  be  sedulously  considered. 

In  view  of  the  defective  character  of  many  of  the  author's  negatives, 
the  greatest  praise  belongs  to  Mr.  William  Kurtz,  to  whose  artistic  taste, 
skill,  and  versatility  is  due  their  excellent  reproduction  by  pliototypo- 
graphic  process. 

Proper  credit  is  given  for  the  lithographic  plates  co|)ied  from  Rosen- 
bach,  for  the  excellent  microphotographs  reproduced  from  Koch's  classi- 
cal reports,  and  for  a  few  other  illustrations  borrowed  from  Esmarch, 
Henke,  and  Bumm.  » 

In  conclusion,  the  author  may  be  permitted  to  express  the  hope  that, 
by  pubHshing  his  share  of  experience  gathered  from  a  modest  public  and 
private  practice,  he  may  succeed  to  somewhat  propagate  and  popularize 
the  principles  and  practice  of  antiparasitic  surgery. 

New  York,  September  3,  1887. 


/• 


CONTENTS 


Pakt  I.— asepsis. 

CHAPTER  I.  PAGE 

What  are  Sepsis  and  Asepsis! 3 

CHAPTER  II. 

Aseptic  Wounds — Aseptic  Treatment     ...                 5 

I.  General  remarks           ............  5 

II.  Rules  of  surgical  cleanliness         .         .         .         .         .         .         .         .         .         .  7 

1.  Hands V 

2.  The  instruments  ............  1 

3.  Wound  irrigation Y 

4.  Sponges 8 

5.  Materials  for  ligatures  and  sutures       ........  8 

6.  Drainage-tubes  and  elastic  ligatures 9 

v.  Disinfecting  lotions      ...........  10 

8.  Dressings     .............  11 

(1)  Types  of  dressings 11 

a.  Simple  exsiccation.     Bismuth,  iodoform 11 

f>.  Chemical  sterilization  combined  with  exsiccation.     Dry  dressings           .  12 

c.  Schede's  modification  of  the  dry  dressing,  favoring  the  organization  of 

the  moist  blood-clot 12 

d.  Simple  chemical  sterilization.     Moist  dressings     .....  13 

(2)  Preparation  of  di'essings 14 

a.  Gauze            ............  14 

(a)  Corrosive-sublimate  gauze 15 

(b)  lodoformized  gauze  .         .         .         .         .         .         .         .         .15 

b.  Absorbent  cotton,  or  common  cotton  batting  .         .         .         .         .15 

c.  Sawdust 16 

d.  Moss 1*7 

III.  Practical  application  of  rules        ..........  IT 

1.  In  operating         ............  17 

2.  Change  of  dressings     ...........  20 

IV.  Aseptic  measures  in  emergencies          .........  23 

Operating  bag  and  kit .25 

CHAPTER  III. 

Soiled  Wounds. — Antiseptic  Treatment. — Difference  between  Aseptic  and  Antiseptic 

Methods. — Illustration  of  Antiseptic  Method   ........  27 


Vlll 


CONTENTS. 


CHAPTER  IV. 

Special  Rtles  regarding  the  Treatment  of  Accidental  Wounds 
I.  Temporary  measures    . 
II.  Definitive  relief   . 

1 .  Contaminated  wounds 

2.  Aseptic  wounds 

3.  Gunshot  wounds 


PAGE 

29 
29 
31 
31 
33 
34 


CHAPTER  V. 

Special  Application  of  the  Aseptic  Method 
A.  General  principles    .... 
I.  Technique  of  surgical  dissection 

II.  Sutures 

III.  Drainage 

h.  Application  of  aseptic  method  to  diverse  organs  and 
I.  Ligatures  of  arteries  in  their  continuity 
II.  Extirpation  of  tumors 

Preservation  of  asepsis 

Safe  removal        .... 

Complete  removal 

III.  Amputation  of  limbs 

1.  Aseptics  and  antiseptics  of  amputation 

a.  Clean  cases      .... 

b.  Mildly  septic  cases 

c.  Septic  cases  of  greater  intensity 

2.  Hemorrhage        .... 

a.  Artificial  anaemia 

b.  Ligatures  and  final  haemostasis 

3.  Securing  of  a  good  stump    . 

IV.  Operations  about  non-suppurating  joints 

1.  Puncture  and  irrigation 

2.  Arthrotomy  .... 

a.  Hydrops  genu  .... 

b.  Vegetations     .... 

c.  Floating  bodies  of  the  knee-joint 

d.  Suturing  of  the  fractured  patella 

3.  Arthrotomy  for  irreducible  or  habitua 

fracture 
V.  Operations  for  deformities  . 

1.  Knock-knee  and  bow-leg 

2.  Bony  anchylosis  in  a  vicious  position 

3.  Deformed  callus 

4.  Club-foot  and  pes  valgus 
VI.  Plastic  operations 

VII.  Aseptics  of  the  oral  cavity  . 
V'lII.  Laryngeal  operations  . 

1.  Tracheotomy 

a.  Superior  tracheotomy 

b.  Inferior  tracheotomy 

2.  Laryngofi.'^sure     . 

3.  Extirpation  of  the  larynx 


regions 


dislocation,  and  for 


deformity  due  to 


CONTENTS. 


IX 


IX.  Goitre 

X.  Amputation  of  the  breast    . 

XI.  Abdominal  operations 

1.  General  remarks 

2.  Herniotomy 

a.  Herniotomy  for  strangulation 

b.  Radical  operation  for  hernia 

3.  Laparotomy 
a.  Exploratory  incision 
6.  Abdominal  tumors    . 

(a)  General  remarks 

(6)  Special  observations     . 

(a)  Ovarian  tumors 

(j3)  Supra-vaginal  hysterectomy 

(7)  X'ephrectomy 

c.  Gastrostomy     . 

d.  Colotomy 
(«)  Lumbar  colotomy 
(6)  Inguinal  colotomy 

XII.  Hydrocele,  varicocele,  and  castration 

1.  Hydrops  of  the  tunica  vaginahs 

2.  yaricocele  .... 

3.  Castration  .... 
XIIL  Aseptic  operations  on  the  rectum 

1.  General  observations 

2.  Hemorrhoids 

3.  Rectal  tumors 
XIV.  Aseptics  of  the  bladder 

1.  Catheterism 
2  Litholapaxy 
3.  Cystotomy 

a.  Perineal  section 

b.  Suprapubic  section 


PAGE 

107 

109 

115 

115 

117 

119 

128 

133 

133 

133 

133 

140 

140 

143 

145 

146 

147 

147 

148 

149 

149 

151 

152 

154 

154 

154 

157 

159 

159 

161 

162 

162 

163 


Part  II.— ANTISEPSIS. 


CHAPTER  VI. 

Natural  History  of  Idiopathic  Suppitration.— Treatment  of  Suppuration 
I.  The  cause  of  suppuration,  or  phlegmon 
II.  Portals  of  infection 

1.  Infection  through  lesions  of  the  skin    . 

2.  Infection  through  lesions  of  the  mucous  membranes 

III.  Entrance,  progress,  and  localization  of  the  infection    . 

Mechanical  irritation 

Chemical  and  caloric  irritation     .         .         .         • 

IV.  Development  of  phlegmon 

V.  Spread  of  suppuration 

VI.  Diagnosis  and  treatment  of  phlegmon 


169 
169 
171 
171 
172 
.173 
175 
176 
177 
179 
184 


CONTENTS. 


1.  General  pvlnciples        ........ 

a.  Supcrlicial  suppuration,  or  septic  ulcer      .... 

b.  Cutaneous  and  subcutaneous  phlegmon     .... 

c.  Deep-seated  or  subfascial  phlegmon.     Lymph-gland  abscess 

d.  Acute  infectious  osteomyelitis  ..... 

e.  Chronic  suppuration  due  to  bone  necrosis.     Necrotomy     . 

2.  Phlegmonous  affections  of  some  special  regions  . 

a.  Face.     Floor  of  the  mouth.     Neck.     Temporal  and  mastoid  regions 

(a)  Face 

(6)  Neck 

(o)  Fauces  and  pharynx         .... 

(j8)  Submaxillary  and  parotid  cynanche 

(7)  Acute  glandular  abscesses  of  the  anterior  and  lateral  cervical  regions 

(5)  Glandular  abscesses  of  the  temporal,  mastoid,  and  occipital  regions 

b.  Mammary  and  retro-mammary  abscess 

c.  Empyema  ....... 

d.  Phlegmon  of  the  palmar  aspect  of  the  hand,  of  the  arm,  and  axilla 

e.  Suppurative  affections  of  the  lower  extremity  . 
(«)  Ingrown  toe-nail  ..... 
(6)  Chronic  ulcers  of  the  leg     . 
(c)  Acute  suppuration  of  the  prepatcUary  bursa 
((/)  Acute  suppuration  of  the  knee-joint     . 
(e)   Suppuration  of  the  inguinal  glands 

f.  Perityphlitic  abscesses      ..... 

g.  Abscess  of  the  hver 

h.  Lumbar  abscesses    ...... 

i.  Anal  abscess.     Fistula  in  ano 


PAGE 
184 

185 
185 
189 
191 
194 
208 
208 
209 
211 
211 
217 
220 
221 
223 
226 
230 
239 
239 
241 
242 
242 
245 
246 
251 
251 
254 


CHAPTER  VIL 


Erysipelas  and  Psecdo-Ertsipelas 


259 


Paet  III.— TUBERCULOSIS: 

ITS   ASEPTIC    AND   ANTISEPTIC   TREATMENT. 


CHAPTER  VIII. 

Natpral  History  and  Treatmknt  of  Tuberculosis 
I.  Etiology  of  tuberculosis.  Tubercle  bacillus 
II.  Complication  of  tuberculosis  with  pyogenic  or  suppurative  infection 

III.  Treatment  of  tuberculosis 

(ieneral  principles 

Local  treatment  of  tuberculosis  .... 

1.  Cutaneous  tuberculosis.     Lupus  .... 

2.  Tuberculosis  of  the  mucous  membranes 

3.  Tuberculosis  of  the  lymphatic  glands,  or  scrofula 

4.  Tuberculosis  of  tendinous  sheaths 

5.  Tuberculosis  of  bone.     Caries.     Cold  abscess 

6.  Tuberculosis  of  joints.     White  swelling 


263 
263 
207 
267 
267 
268 
268 
269 
269 
271 
273 
275 


CONTENTS. 

xi 

PAGE 

General  part 

.     275 

a.  Technique  of  joint 

exsection          .         .         .         . 

.     275 

(a)  Septic  injection  from  without  .... 

.     275 

(6)  Complete  removal  of  tuberculous  tissues 

.     276 

(c)  Control  of  haemorrhage            .... 

.     276 

(d)  Preservation  of  function           .... 

.     276 

h.  After-treatment    . 

.     277 

Special  part 

.     278 

a.  Shoulder-joiiit 

.     278 

h.  Elbow 

. 

.     280 

c.  Wrist  and  hand     . 

.     284 

(/.  Hip-joint 

.     285 

<?.  Knee-joint  . 

.     287 

/.  Ankle  and  foot     . 

*        "        "        " 

.     293 

Part  IV.— GONOREHGEA  : 

ITS   ANTISEPTIC    TREATMENT. 

CHAPTER  IX. 

Natural  History  and  Treatment  of  Gonorrhcea   ........  299 

I.  Etiology  of  gonorrhoea.     Gonococcus 299 

II.  Treatment  of  gonorrhoea .  301 

1.  Acute  gonorrhoea.     Clap 301 

a.  Anterior  gonorrhoeal  urethritis          ........  302 

h.  Deep-seated  gonorrhoeal  urethritis     ........  304 

2.  Chronic  gonorrhoea.     Gleet           .........  307 

a.  Inflammatory  stenosis  (incipient  stricture)  and  permanent  or  cicatricial 

stricture  of  the  urethra       .........  307 

(a)  Anterior  urethra 307 

(6)  Deep  urethral  strictures  .........  313 

h.  Vegetations  of  the  urethra        .         .         .         .         .         .         .         .         .315 

c.  Granular  urethritis             ..........  315 

d.  Chronic  catarrh  of  the  posterior  part  of  the  urethra,  and  chronic  cystitis  .  315 


Part  V.— SYPHILIS  : 

ASEPTEC   AND   ANTISEPTIC   TREATMENT   OF   ITS   EXTERNAL  LESIONS. 


CHAPTER  X. 

Aseptics  and  Antiseptics  applied  to  External  Syphilitic  Lesions      ....  321 

1.  Aseptic  treatment  of  primary  induration      .......  321 

2.  Antiseptic  treatment  of  the  primary  syphilitic  ulcer      .....  324 

a.  Chemical  sterilization  and  surface-drainage  by  medicated  moist  dressings  324 

h.  Chemical  sterilization  by  strong  caustics  .......  325 

c.  Sterilization  by  the  actual  cautery     ........  326 


PART   I, 


ASEPSIS 


CHAPTEE  I. 

WBAT  ARE  SEPSIS  AND  ASEPSIS? 

It  is  not  intended  here  to  enter  into  an  exhaustive  exposition  of  the 
essence  of  suppuration  and  the  whole  complex  of  conditions  known  under 
the  name  of  sepsis.  It  may  suffice  for  the  present  to  give  a  rough  out- 
line of  the  views  that  prevail  regarding  the  causation  of  the  conditions  in 
question. 

Albuminoid  substances,  such,  for  instance,  as  blood  or  blood-serum — 
in  fact,  all  the  tissues  of  the  dead  animal  body — will  become  putrid  under 
certain  well-known  conditions.  These  are,  first,  moisture  ;  secondly,  a  cer- 
tain temperature  called  warmth,  for  short ;  and,  thirdly,  the  presence  of 
living  organisms,  or  fungi,  named  schizomycetes,  better  known  under  the 
name  of  bacteria  and  micrococci.  If  all  these  factors  are  present,  the  ani- 
mal substance  in  question  will  ferment  or  putrefy.  Absence  of  any  one  of 
these  factors  will  be  sufficient  to  prevent  decomposition.  To  illustrate  this 
proposition,  we  shall  mention  common  facts.  Fresh  meat  or  fish,  well 
dried,  can  be  indefinitely  preserved  ;  freezing  and,  to  a  certain  extent,  roast- 
ing will  also  prevent  its  spoiling ;  and,  lastly,  exclusion  of  micro-organisms 
by  air-tight  packing  or  sealing,  after  boiling,  will  insure  preservation  for  an 
indefinite  length  of  time. 

The  active  agents  of  decomposition  are  the  micro-organisms,  which  will 
develop  at  once  their  disintegrating  activity  as  the  conditions  favorable  to 
their  development  (moisture  and  a  certain  temperature)  are  present. 

We  then  either  thoroughly  dry  the  substance  to  be  preserved  or  produce 
and  preserve  a  very  low  or  very  high  temperature  in  it,  all  of  which  will  pre- 
vent the  development  of  fungi.  Exclusion  of  the  fungi  is  herein  unneces- 
sary. The  third  mode  of  preservation  is  that  employed  in  canning  meats. 
They  are  first  boiled  thoroughly,  then  the  vessel  wherein  this  boiling  was 
done  is  hermetically  sealed  while  the  substance  is  still  very  hot.  Here  we 
have  a  combination  of  first  destroying  the  vitality  of  such  fungi  as  are  con- 
tained in  the  meat  before  boiling,  and,  secondly,  exclusion  of  access  of  new 
micro-organisms  to  the  sterilized  substance. 

Note. — The  most  effective  sterilizer  is  the  actual  cautery.  It  not  only  destroys  all  the  nox- 
ious germs  contained  within  the  tissues,  but  at  the  same  time  provides  these  with  an  often  dry 
and  always  hermetic  seal  against  further  infection.    If  the  eschar  and  its  vicinity  be  well  dusted 


4  RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

with  iodoform  powder,  it  will  often  happen  that  complete  cicatrization  will  take  place  beneath 
its  protection,  even  before  the  detachment  of  the  eschar. 

All  accidental  or  surgical  wound  presents  conditions  that  are  eminently 
favorable  for  the  development  of  the  fungi  in  question.  The  oozing  blood 
and  lymph,  the  bruised  and  dead  cells  of  the  various  exposed  tissues,  fur- 
nish, severed  from  their  natural  connections,  the  moist  pabulum  of  a  proper 
temperature.  The  myriads  of  particles  of  filth  or  dust,  filling  the  air  in  all 
inhabited  localities,  contain,  according  to  indubitable  evidence,  a  very  large 
proportion  of  spores  or  seeds  that,  on  falling  upon  the  wound  and  its  secre- 
tions, promptly  develop  into  fungi,  and  at  once  set  up  a  fermentative  process 
known  as  decomposition. 

The  products  of  this  fermentation  are  more  or  less  highly  poisonous  sub- 
stances— Bergmann's  sepsin,  or  the  ptomaines  of  the  French  authors.  They 
promptly  set  up  local  changes  in  the  shape  of  inflammation,  and  cause  sys- 
temic trouble — that  is,  septic  fever. 

It  is  further  necessary  for  us  to  know  that  in  septic  processes  of  a  wound 
not  only  the  ptomaines  are  absorbed  by  the  lymphatics,  but  that  often  an 
actual  invasion  of  the  living  tissues  by  the  fungi  will  take  place,  and  that 
the  lymphatics  and  veins  will  also  serve  as  channels  for  the  importation  of 
dangerous  quantities  of  fungi  into  the  circulation.  .  Secondary  deposits, 
metastases,  will  then  easily  occur. 

Clinical  observers  properly  distinguish  between  different,  more  or  less 
intense  forms  of  septic  infection,  in  which  bacteriology,  however,  does  not 
always  demonstrate  correspondingly  different  forms  of  fungi.  On  the  other 
hand,  it  is  known  that  impoverished  nutrition,  but  especially  a  certain  mor- 
bid state,  namely,  diabetes  mellitus,  presents  an  extremely  favorable  con- 
dition for  the  development  of  bacterial  sepsis. 

Eegarding  syphilis  and  tuberculosis,  this  can  not  be  said,  as  it  is  not 
difficult  in  these  states  to  prevent  suppuration  of  accidental  or  surgical 
wounds. 

Case. — In  1879  the  author  removed  from  the  lumbar  region  of  a  young  brewer  a 
good-sized  lipoma.  His  skin  was  covered  at  the  time  with  a  recent  syphilitic  roseola 
following  a  chancre.  Under  ordinary  antiseptic  precautions  prompt  union  by  the  first 
intention  followed,  although  the  treatment  was  altogether  ambulatory,  the  pa,tient 
having  been  operated  on  and  treated  throughout  at  the  German  Dispensary. 

Prompt  primary  healing  of  the  wounds  caused  by  the  extirpation  of  syphilitic  buboes 
is  a  rather  common  experience  in  the  syphilitic  ward  of  the  German  Hospital. 

The  excellent  results  obtained  after  exsections  of  tuberculous  joints  are  also  proof 
positive  of  the  assertion  that  tuberculosis  in  itself  does  not  dispose  to  suppuration  and 
sepsis,  and  that  prevention  of  septic  processes  in  the  wounds  of  the  victims  of  tubercu- 
losis is  not  difficult. 

Diabetes  mellitus,  however,  does  undoubtedly  heighten  the  disposition  to  septic 
conditions.  Ordinary  antiseptic  precautions  often  fail  to  j)revent  suppuration  ;  hence, 
an  injury,  or  tlie  necessity  of  a  bloody  operation  in  a  diabetic,  should  never  be  treated 
ligiitiy. 

It  is  the  immortal  achievement  of  Lister  to  have  first  attributed  to  fer- 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  5 

mentative  influences  the  disturbances  of  repair,  and  to  liave  led  wound- 
treatment  into  a  rational,  hence  successful,  direction. 

Modern  wou7icl-treatment  is  based  entirely  on  the  old  and  luell-known 
principles  of  the  preservation  of  organic  substances.  Of  the  several  modes 
of  preservation,  freezing  is  the  only  one  that  is  inapplicable  in  human  sur- 
gery. Exsiccation,  however,  and  burning  with  the  actual  cautery  (roast- 
ing) ;  then  chemical  sterilization  by  germicides,  and  the  combination  of 
chemical  sterilization  with  exsiccation,  contain  the  essence  of  aseptic  sur- 
gery. They  insure  wounds  against  decomposition,  and  are  a  secure  pre- 
ventive of  suppuration. 


CHAPTER   II. 
'    , ASEPTIC   WOUNDS— ASEPTIC   TREATMENT. 
I.     GENERAL    REMARKS. 

SupposiXG  that  the  skin  in  the  region  to  be  operated  on  be  shaved,  then 
energetically  scrubbed  in  hot  water  with  soap  and  a  clean  brush  for  five 
minutes,  then  the  surgeon's  hands  be  scrubbed,  likewise  his  knife,  and  now 
an  incision  be  made  through  the  skin  :  supposing  that  this  happen  in  an 
atmosphere  free  from  particles  of  dry  filth  called  dust :  such  a  wound  could 
be  safely  termed  a  clean  or  aseptic  one.  All  particles  of  filth  adhering  to 
skin,  hands,  and  instrument  were  removed  by  this  simple  process  of  scrub- 
bing, and  no  new  particles  could  settle  down  out  of  the  atmosphere,  which 
we.  assumed  to  be  free  from  dust. 

Experience  has  taught  that  such  a  wound,  however  large,  Avill  heal 
without  suppuration,  first,  if  its  edges  be  approximated  by  sutures  made 
with  a  clean  needle  and  clean  wire,  silk,  or  gut ;  and,  secondly,  if  the  im- 
munity from  an  invasion  of  filth  be  maintained  until  the  bloody  serum 
marking  the  line  of  union  become  dry. 

But  we  can  vary  our  experiment,  and  show  that  a  wound  can  heal  with- 
out suppuration  even  if  contact  of  the  walls  of  the  same  be  imperfect  or 
none. 

Case. — Mrs.  .J.  B.,  aged  forty-nine ;  'brancliial  cyst  of  tlie  submaxillary  region  of  the 
size  of  an  orange.  Had  been  punctured  a  number  of  times.  Oct.  7,  1882. — Incision  of 
six  inches  in  length;  difficult  extirpation.  The  large  vessels  of  the  neck  were  freely 
exposed,  a  considerable  affluent  of  the  deep  jugular  vein  was  deligated.  Catgut  used  was 
rather  brittle.  Suture  and  drainage  of  the  large  wound.  Antiseptic  dressings.  Imme- 
diately after  the  operation  patient  had  a  severe  coughing  spell.  Oct.  12.— On  changing 
the  dressings  it  was  found  that  the  interior  of  the  wound  was  distended  by  a  massive 
blood-clot,  giving  an  appearance  as  though  the  tumor  had  not  been  removed  at  all. 
3 


6  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Sanguinolent  serum  was  discharging  from  the  drainage-tuhe.  Dressings  renewed. 
Oct.  16. — Tumor  much  diminished  in  size.  Drainage-tube  removed.  Oct.  30. — 
Wound  firmly  healed;  outline  of  neck  normal.     Throughout,  normal  temperatures. 

Here  we  see  that  uudoubtedly  secondary  venous  haemorrhage  had  taken 
place  into  the  large  cavity  of  the  wonnd.  The  distention  did  not  reach  a 
sufficient  degree  to  produce  a  rupture  of  the  line  of  sutures.  The  enormous 
clot  was  rapidly  absorbed,  and  the  wound  healed  without  suppuration, 
though  not  by  primary  adhesion.  If  the  wound  had  not  been  aseptic, 
putrefaction  of  the  clot  and  dangerous  septic  processes  would  have  inevit- 
ably followed. 

Still  more  curious  is  the  course  of  an  aseptic  wound  that  is  not  united 
at  all,  but  is  left  gaping,  provided  that  suitable  means  are  employed  to- 
preserve  its  aseptic  character. 

Case. — Mrs.  C.  T..  aged  forty-three,  came  from  Ohio  to  have  a  syphilitic  defect  of  the 
nose  repaired.  Total  rhinoplasty,  Sept.  18,  1883,  at  Mount  Sinai  Hospital.  A  suitable 
flap  containing  the  periosteum  was  raised  from  the  forehead.  The  edges  of  the  frontal 
wound  could  not  be  drawn  together,  therefore  a  properly  shaped,  well-disinfected 
piece  of  rubber  tissue  was  laid  on  it,  and  this  was  covered  with  an  iodoform  dressing. 
Sept.  23. — Stitches  removed  from  nasal  sutures.  Dressing  on  forehead  dry,  therefore 
it  was  left  undisturbed.  Oct.  1. — Dressing  of  frontal  wound  being  removed,  the  rubber- 
tissue  covering  became  visible;  after  this  was  taken  away  the  edges  of  the  wound 
were  found  to  be  cicatrized  to  the  width  of  half  an  inch  on  both  sides.  A  moist, 
fresh-looking  remnant  of  the  blood-clot  was  still  covering  a  strip  of  the  middle  of  the 
wound.  No  suppuration  whatever.  Dressings  renewed.  Oct.  6. — Entire  wound 
cicatrized  with  the  exception  of  a  spot  as  large  as  a  penny  at  the  upper  end.  Oct.  10. 
— Discharged  cured. 

Here,  then,  is  an  example  of  the  now  commonly  observed  fact  that  a 
gaping  defect  will  cicatrize  over  without  suppuration  if  putrefactive  changes 
be  excluded  from  the  clot  filling  up  the  gap.  This  observation  involves  a 
radical  difference  from  the  old  tenet  that  whatever  wound  does  not  heal 
by  primary  adhesion  must  heal  by  suppuration.  A  third  possibility  has 
become  demonstrable,  for  which  older  pathology  had  no  explanation. 

It  is  necessary  to  state  that  in  both  of  the  latter  examples  the  condition 
of  a  dustless  atmosphere  during  the  time  of  the  operation  was  not  present ; 
the  operations  were  done  in  ordinary  rooms,  openly  communicating  with 
the  dusty  streets  of  New  York,  yet  the  behavior  of  the  wounds  was  per- 
fectly correct. 

The  extreme  difficulty  of  preparing  and  maintaining  a  dustless  atmos- 
phere in  a  room  of  an  inhabited  locality  is  well  known  to  everybody,  and, 
as  a  matter  of  fact,  the  general  practitioner  must  and  will  have  to  do  his 
surgery  in  more  or  less  dusty  rooms.  Since  the  procurement  of  this  con- 
dition is  practically  unattainable,  frequent  irrigation  or  rinsing  of  the 
wound  becomes  a  necessity.  But  even  a  constant  and  powerful  stream  of 
fluids  will  not  be  able  to  dislodge  all  the  particles  of  dust  that  may  have 
settled  down  upon  and  insinuated  themselves  into  the  nooks  and  crevices 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  7 

of  a  wound.  Hence  it  is  desirable  to  employ  a  li([uid  that,  aside  from  its 
non-irritant  quality,  will  have  the  property  of  neutralizing  or  rather 
extinguishing  the  noxious  effects  of  those  particles  of  dust  that  can  not 
be  washed  away  by  the  irrigation,  but  remain  imbedded  in  the  tissues. 
This  is  chemical  sterilizatioti. 

Different  disinfecting  solutions  are  used  for  this  purpose  to  answer 
various  requirements.  Their  composition  and  uses  will  be  mentioned  here- 
after. 

Note. — Kumniel,  of  Hamburg,  has  shown  that  a  dustless  operating-room  can  be  had  in  a 
well-appointed  hospital,  and  Xeuber,  of  Kiel,  has  excellent  results  from  operations  done  in  such 
a  dustless  room,  with  well-cleansed  hands,  apparatus,  and  instruments,  withoul  the  employment 
of  antiseptic  fluids.  Even  the  dressings  used  are  not  impregnated  with  any  antiseptic  chemical, 
but  are  merely  "  sterilized "  by  being  exposed  to  dry  heat.  No  sponges  are  used,  all  blood 
being  removed  with  a  sterilized  solution  of  common  salt  (6  :  1000),  which  is  absolutely  unirri- 
tating,  and  certainly  forms  the  most  gentle  manner  of  cleansing  a  wound. 


n.     RULES    OF    SURGICAL    CLEANLINESS. 

1.  Hands. — The  hands  and  forearms,  especiallij  the  finger-nails,  of  the 
surgeon  and  his  assistants  should  be  v/ell  scrubbed  in  hot  water  with  soaj) 
and  brush  for  five  minutes  ;  likewise  the  region  of  the  body  of  the  patient 
to  be  operated  on  after  carefully  shaving  off  the  hair.  After  this  follows  an 
immersion  of  the  hands  in  corrosive  sublimate  lotion  for  one  minute. 

Note  1 . — Kiimmel's  recommendation  of  green  soap  (potash  or  soft  soap)  is  excellent,  on  ac- 
count of  its  great  solvent  properties. 

Note  2. — Rings,  especially  those  having  stone  settings,  should  never  be  worn  by  the  surgeon 
or  his  aids  in  an  operation.  Bangles,  and  bracelets  of  female  nurses  should  not  be  tolerated. 
Every  one's  arms  should  be  bared  and  scrubbed  to  the  elbows. 

2.  The  instruments  should  be  subjected  to  a  careful  and  minute  cleans- 
ing with  soap  and  brush,  especial  care  being  taken  to  remove  dry  particles 
of  blood,  pus,  etc.,  from  the  grooves  and  behind  the  clasps  of  the  more  com- 
posite instruments,  which  ought  to  be  taken  apart  each  time  for  cleansing. 
They  should  be  immersed  for  ten  minutes  in  a  three-per-cent  solution  of 
carbolic  acid  before  use. 

Note. — The  surgeon  should  leam  to  get  along  with  as  few  instruments  as  possible.  In 
selecting  instruments,  preference  should  be  given  to  the  most  simple.  The  best  instruments  are 
those  having  smooth  and  well-polished  surfaces ;  grooved  or  roughened  handles  are  hard  to  clean 
and  unnecessary. 

3.  Wound  Irrigation. — During  the  operation  the  wound  should  be  fre- 
quently irrigated  with  the  proper  kind  of  a  disinfecting  fluid  ;  the  hands 
of  the  surgeon  and  his  assistants  should  be  also  washed  at  not  too  long 
intervals  in  a  disinfecting  fluid  (corrosive  sublimate,  1  :  1000)  ;  the  instru- 
ments should  be  kept  immersed  in  a  three-per-cent  solution  of  carbolic 
acid  (which  is  the  least  injurious  to  them). 

Note. — Whenever  any  one  of  those  engaged  at  an  operation  touches  a  not  disinfected  object 
— ^hands  a  chair,  opens  the  window  or  door,  helps  the  anaesthetizer  during  a  vomiting  spell  of 


8  RULES  OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 

the  patient,  scratches  his  face,  or  wipes  his  nose — it  if  absoluteli/  necessary  that  his  hands  be 
scrubbed  and  disinfectpd  anew.  Instruments  that  are  accidentally  dropped  should  be  left  un 
touched.  Raw  assistants,  and  cspeciallii  nurses,  male  and  female,  trained  or  untrained,  should  be 
earnestlv  instructed  beforehand,  and  constantly  watched  afterward,  regarding  this  all-important 
discipline. 

4.  Sponges  should  be  beaten  free  from  calcareous  particles,  then  im- 
mersed for  fifteen  minutes  in  dilute  muriatic  acid  to  dissolve  the  remnant 
of  lime,  washed  in  cold  water,  then  thoroughly  kneaded  by  hand  with  green 
soap  in  hot  water  for  five  minutes,  rinsed,  and  then  immersed  in  a  five-per- 
cent solution  of  carbolic  acid,  in  which  they  remain  until  required  for  use. 
Sponges  used  once  in  an  aseptic  operation  can  be  used  again.  Careful  wash- 
ing out  with  green  soap  and  hot  water  of  all  the  remnants  of  fibrin  and 
blood,  then  immersion  in  a  five-per-cent  solution  of  carbolic  acid,  is  suffi- 
cient. It  is  not  good  to  use  too  many  sponges  at  an  operation.  When  sat- 
urated with  blood  at  an  operation,  they  should  be  washed  free  from  it  in 
Tiot  water,  then  thrown  into  a  basin  filled  with  carbolic  solution,  and  hence 
handed  to  the  surgeon.  Carbolic  acid  is  preferable  for  preservation  of 
sponges  until  use,  because  it  does  not  become  decomposed  and  inert,  as,  for 
instance,  corrosive  sublimate. 

Note. — Selected  Florida  sponges  are  cheap  and  good.  In  New  York  a  pound  can  be  bought 
for  about  two  dollars,  each  sponge  costing  on  an  average  two  cents. 

5.  Materials  for  Ligatures  and  Sutures.— Well-prepared  catgut  of  differ- 
ent thicknesses  will  answer  every  purpose  for  ligatures  and  sutures.  The 
finest  suture  work  on  the  intestines  can  be  neatly  and  reliably  done  with 
catgut  No.  0.  The  most  massive  pedicle  can  be  safely  tied  with  catgut  No. 
4,  For  ordinary  ligatures  and  sutures,  No.  1  will  be  most  convenient,  and 
should  constitute  the  bulk  of  the  surgeon's  supply. 

The  simplest  way  of  preparing  catgut  is  Kocher's  :  Immerse  catgut  for 
twenty-four  hours  in  good  oil  of  juniper  (ol.  juniperi  baccarum,  oil  of  the 
ierry,  not  the  oil  gained  from  the  wood)  ;  transfer  into  and  preserve  in 
absolute  alcohol  until  use.  Alcohol  keeps  catgut  hard  and  firm,  yet  flexible. 
Carbolic  acid  or  corrosive  sublimate  will  make  it  brittle  and  weak.  Where 
it  is  desirable  to  prevent  too  early  absorption,  as,  for  instance,  in  intestinal 
sutures,  a  hardening  process  should  be  added  to  the  disinfection.  The  arti- 
cle should  be  washed  in  alcohol,  then  placed  into  a  quart  of  a  five-per-cent 
solution  of  carbolic  acid  containing  thirty  grains  of  bichromate  of  potash. 
Forty-eight  hours'  immersion  will  produce  catgut  that  will  resist  the  action 
of  the  living  tissues  for  a  week  or  longer.  Large-sized  catgut  needs  a  longer 
immersion.     Wind  up  on  bobbins. 

Note  1. — Good  catgut  can  be  procured  from  L.  H.  Keller  &  Co.,  64  Nassau  Street,  New 
York,  for  a  moderate  price.  Dry  preservation  makes  catgut  more  suitable  for  transportation : 
Immerse  the  prepared  article  for  five  minutes  in  ether,  100  ;  iodoform,  5.  Take  out  and  place  in 
a  well-corked,  wide-mouthed  bottle.     A  film  of  iodoform  will  cover  each  thread. 

Note  2. — The  author  ob.served  once  immistakablc  mound  infection  by  improperly  kept  catgut. 
Case. — Jenny  Marks,  servant-girl,  aged  twenty,  admitted  November  10,  1883,  to  Mount  Sinai 
Ho.«pital  with  habitual  subcoracoid  dislocation  of  the  right  shoulder-joint.     "Sprain"  had  been 


ASEPTIC   WOUNDS— ASEPTIC    TREATMENT.  9 

diagnosticated  by  a  physician,  seven  weeks  previous  to  her  admission,  who  ordered  a  liniment, 
On  admission,  reduction  was  easily  effected  by  manipulation,  but  the  weight  of  the  limb  was  suf- 
ficient to  reproduce  the  dislocation.  A  plaster-of-Paris  jacket,  inclosing  the  reduced  arm,  was 
applied  and  worn  for  four  weeks  without  any  effect.  Dec.  llih. — The  joint  was  freely  opened 
by  an  anterior  longitudinal  incision,  when  it  became  evident  that  the  tendency  to  dislocation  was 
due  to  laxity  or  redundancy  of  the  anterior  part  of  the  capsular  ligament.  By  two  semi-ellipti- 
cal incisions,  a  piece  of  the  capsule  one  inch  long  and  half  an  inch  in  width  was  removed.  The 
capsular  as  well  as  the  muscular  and  the  skin  wound  were  united  by  three  tiers  of  interrupted 
catgut  sutures,  a  drainage-tube  having  previously  been  carried  just  within  the  capsule.  The 
next  day  moderate  fever  (101°  Fahr.),  but  great  dejection,  headache,  and  vomiting  were  observed 
the  patient  complaining  of  much  pain  in  the  joint.  Dec.  13th. — The  thermometer  indicated 
103°  Fahr.,  with  a  corresponding  increase  of  the  general  disturbance.  The  patient  was  anaes- 
thetized, and  the  wound  was  exposed.  No  redness,  only  slight  oedema  was  visible.  The  wound 
was  reopened.  Firm  agglutination  was  present  everywhere  except  in  four  places,  where  swollen, 
discolored  ligatures  applied  to  the  circumflex  artery  and  some  smaller  vessels  were  seen  sur- 
rounded by  a  halo  of  yellowish,  semi-fluid,  broken-down  tissue,  evidently  representing  small 
abscesses  that  were  forming  about  the  catgut  ligatures.  They  were  removed,  the  wound  was 
irrigated  with  carbolic  lotion,  and  packed  with  gauze.  The  fever  fell  off  at  once,  and  no  further 
complication  interrupted  the  course  of  healing.     The  habitual  luxation  was  also  cured. 

Silh  can  be  rendered  iinirritaut  by  boiling  it  for  an  hour  in  a  five-per- 
cent solution  of  carbolic  acid  (Czerny),  then  preserving  in  alcohol. 

Silk-worm,  gut  is  excellent  material  for  suturing.  It  is  prepared  like 
silk,  and  before  use  should  be  soaked  awhile  in  carbolic  lotion  to  make  it 
supple.     Its  advantage  :  it  is  easy  to  thread. 

6.  Drainage-tubes  and  elastic  ligatures  are  cut  into  proper  lengths— that 
is,  a  little  shorter  than  the  height  of  the  wide-mouthed  bottle  in  which  they 
are  kept.  This  is  filled  with  a  five-per-cent  solution  of  carbolic  acid,  that 
should  be  renewed  from  time  to  time.  The  tubes  will  always  occupy  an 
upright  position  in  the  bottle,  and  can  be  taken  out  easily. 

Note. — Rubber  tubing  of  black  material  is  preferable  to  the  coarser  and  unyielding  white 
stuff,  on  account  of  its  softness  and  pliability. 

Theoretically  speaking,  a  perfectly  aseptic  wound  does  not  require  any 
drainage.  If  the  secretions  following  an  operation  or  injury  do  not  contain 
anything  that  is  capable  of  inducing  putrid  changes,  they  will  be  absorbed, 
and  will  not  cause  any  disturbance  in  the  wound  or  the  general  health.  The 
large  blood-clot  around  a  fractured  bone  is  harmlessly  absorbed ;  a  large 
blood-clot  in  an  aseptic  operation  wound  will  be  also  absorbed  without  local 
or  general  disturbance,  as  Mrs.  B.'s  case  (see  page  5)  has  shown.  The 
experienced  surgeon  who  has  mastered  the  technique  of  asepticism  will  not 
hesitate  to  close  up  without  drainage  a  small  wound,  as,  for  instance,  after 
deligating  the  subclavian  or  iliac  arteries.  But,  in  operations  where  large 
surfaces  were  long  exposed,  and  where  the  wound  is  very  irregular,  the  pos- 
sibility of  a  however  slight  and  unavoidable  contamination  should  always 
be  kept  in  view.  Vents  should  therefore  be  provided  in  the  shape  of  prop- 
erly placed  drainage-tubes  for  the  easy  egress  of  secretions,  possibly  contain- 
ing elements  of  future  decomposition.  If  the  healing  be  prompt,  the  tubes 
can  be  withdrawn  on  the  fourth  or  sixth  day.  In  case  of  suppuration, 
bland  or  destructive,  they  will  be  in  place,  and  very  opportune. 


10  RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

7.  Disinfecting-  Lotions. — With  a  few  exceptions  (very  large  wounds 
requiring  }3rolongecl  irrigation,  and  in  operations  involving  the  peritoneum), 
two  lotions  will  be  found  sufiicient.  For  the  immersion  of  the  instruments, 
a  tliree-xier-cent  solution  of  carbolic  acid,  and  for  the  irrigation  and  disin- 
fection of  hands  and  skin,  a  solution  of  corrosive  sublimate  of  1  :  1,000 — 
1,500. 

Note. — The  almost  exclusive  use  by  the  author  of  carbolic  acid  and  corrosive  sublimate 
as  germicides  is  intentional.  It  was  determined  by  the  fact  that  these  substances  are,  Jirst, 
thoroughly  reliable  and  highly  efPective ;  secondly,  procurable  almost  everywhere,  in  the 
country  store  as  well  as  in  the  city ;  thirdly,  because  adherence  to  certain  carefully  selected 
substances  results  in  a  thorough  knowledge  of  their  proper  use  under  varying  conditions. 

Boiled  v/ater  is  preferable  as  a  solvent.  It  alone  would  bo  no  doubt  suf- 
ficient if  we  were  absolutely  sure  against  the  introduction  of  filth  into  the 
wound. 

Note. — A  ready  and  handy  way  of  mixing  the  lotions  is  the  following  one : 
Carbolic  Acid. — One  tablespoonful  or  four  teaspoonfuls  to  a  quart  bottle  of  hot  water  will 
make  a  lotion  of  the  strength  of  about  three  per  cent,  reckoning  650  grammes  to  the  ordinary 
wine -bottle. 

Corrosive  Sublimate. — Keep  on  hand  a  few  ounces  of  an  alcoholic  solution  of  the  salt  of  1 :  10 
in  a  glass-stoppered  bottle  (in  boxwood  case  for  transportation).  One  teaspoon ful  of  this  added 
to  a  quart  bottle  of  hot  water  will  make  about  a  1  :  1,500  solution,  which  can  be  weakened  by 
dilution.  The  addition  of  one  teaspoonful  of  cooking-salt  will  prevent  disintegration  of  the  mer- 
curic preparation. 

Boro- Salicylic  Lotion. — In  cases  where  carbolic  or  mercurial  poisoning 
could  be  produced  by  the  use  of  mercuric  or  carbolic  irrigation,  Thiersch's 
solution  is  commendable  as  a  substitute.  It  consists  of  salicylic  acid  2, 
boracic  acid  12,  and  hot  water  1,000  parts.  It  is  non-poisonous,  very  bland, 
and  the  peritoneum  can  be  washed  with  it  with  impunity.  External  wounds 
of  large  size  should  be  also  irrigated  with  this  lotion.  A  final  thorough 
irrigation  with  corrosive  sublimate  should  sterilize  the  wound  before  clos- 
ing it. 

Note. — The  selection  of  different  lotions  should  be  governed  by  the  following  experiences : 
Carbolic  lotions  are  dangerous  to  smcdl  children,  even  in  great  dilution,  and  should  never  be  used 
on  them.  Corrosive  sublimate  is  also  poisonous,  causing  salivation,  and  occasionally  fatal  diph- 
theritic inflaninnition  of  the  ileum  and  the  thick  gut,  if  its  use  is  immoderate.  Wherever  super- 
ficial ulcers  or  inflammations  of  the  cutis  require  the  antiphlogistic  action  of  the  very  diffusible 
carbolic  lotion,  it  should  be  employed  in  the  strength  of  two  or  three  per  cent.  The  continued 
use  of  higher  concentrations  will  corrode  the  tissues,  and  is  otherwise  dangerous. 

Where  a  direct  application  of  the  lotion  to  the  wounded  or  diseased  surface  is  desirable,  as, 
for  instance,  in  all  bloody  operations,  mercuric  bichloride  deserves  the  preference  over  carbolic 
acid.  Even  weak  solutions  (as  1  :  5,000)  have  a  decided  germicidal  power,  and  can  be  used  on 
very  extensive  wounds  for  hours  without  serious  danger  of  intoxication.  The  final  irrigation  of 
an  operation  wound  should  always  be  done  with  a  stronger  (1  :  1,000)  solution.  Abscess  cavities 
will  always  require  the  strongei'  solutions. 

The  groat'.'St  advantage  of  corrosive  su})!imate  over  carljolic  acid  is,  however,  to  bo  sought  in 
its  different  effect  upon  the  fresh  blood-clot  and  the  tissues  exposed  to  its  action  in  a  fresh  wound. 
It  will  be  seen  that  irrigating  an  amputation  wound,  for  instance,  with  carbolic  lotion,  will  each 
time  provoke  very  profuse  oozing.    Vessels  that  had  stopped  bleeding  by  the  formation  of  a  clot 


ASEPTIC  WOUNDS— ASEPTIC    TREATMENT.  H 

withiu  their  cut  ori^ces  begin  to  bleed  anew  after  eaibolic  irrigation.  Tlii.s  is  caused  by  the 
peculiar  macerating  effect  of  carbolic  acid  upon  the  fresh  blood-clot.  Its  color  turns  from  dark 
red  to  a  light  brick-red,  its  toughness  and  cohesion  are  lost,  and  the  slightest  touch  of  a  sponge 
will  suffice  to  detach  it  from  the  orifice  of  cut  vessels,  thus  renewing  the  htcmorrhagc.  Another 
disagreeable  effect  of  carbolic  lotions  upon  wounds  is  the  profuse  discharge  of  bloody  serum 
continuing  for  one  or  two  days  after  the  operation,  rendering  one  or  more  changes  of  dressings 
necessary  within  a  day  or  two,  and  thus  depriving  the  wound  of  needed  rest  at  the  most  critical 
period  of  repair. 

Corrosive  sublimate  does  not  dissolve  clots,  hence  oozing  stops  by  natural  means  during  its 
use.  It  does  not  irritate  the  vaso-motor  nerves  as  carbolic  acid  seems  to  do,  hence  the  oozing 
subsequent  upon  an  operation  done  with  its  aid  is  very  scanty.  Drainage  is  easier,  can  often  be 
altogether  spared ;  no  early  change  of  dressings  is  required,  and  cure  under  one  dressing  is  possi- 
ble, and,  in  fact,  is  the  rule  after  its  proper  use. 

8.  Dressings. — We  have  mentioned  that  there  are  two  ways  of  preserving 
the  aseptic  character  of  a  wound,  viz.,  by  exsiccation  or  by  sterilization  of 
the  secretions.     These  two  methods  can  also  be  advantageously  combined. 


(1)   Ty23es  of  Dressings. 

a.  Simple  Exsiccatiox. — Small,  or  comparatively  small  wounds,  ad- 
mitting of  an  exact  .coaptation  of  the  deeper  as  well  as  their  superficial 
parts  by  suture,  are  exquisitely  fit  for  this  method  of  treatment.  Plastic 
operations  about  the  face  may  serve  as  a  fair  type. 

Bismuth  and  Iodoform. — Certain  finely  powdered  substances,  as  iodo- 
form or  subnitrate  of  bismuth,  have  the  quality  of  rapidly  inspissating  blood 
and  serum  to  a  dry  crust.  Accordingly,  after  the  haemorrhage  has  been 
controlled  and  the  wound  closed  by  suture,  a  quantity  of  the  substance 
chosen  is  dusted  over  the  sutures.  No  further  dressings  are  applied.  The 
escaping  bloody  serum  forms  a  paste  with  the  powder,  which  by  its  steriliz- 
ing property  prevents  decomposition,  while  the  paste  remains  moist.  Eree 
access  of  air  will  hasten  exsiccation,  and  the  dry,  hard  crust  once  formed 
will  securely  prevent  further  ingress  of  dust  into  the  wound.  In  cases 
where  the  powder  is  washed  away  by  profuse  oozing,  the  dusting  has  to  be 
repeated  every  half-hour  after  the  operation,  until  the  object — the  forma- 
tion of  a  dry  crust — is  accomplished. 

Note. — Elderly  subjects  are  prone  to  iodoform  poisoning  if  the  agent  is  too  freely  used.  In 
these  cases  a  mixture  of  equal  parts  of  iodoform  and  bismuth  is  safer. 

Small  cuts,  abrasions,  and  burns  can  also  be  similarly  treated,  care  being 
taken  to  first  render  the  injuries  aseptic  by  ablution  with  corrosive  subli- 
mate lotion. 

Note. — Acetic  Acid. — An  excellent  way  of  treating  small  injuries  is  to  wash  them  as  soon  as 
possible — after  staunching  the  haemorrhage — with  pure  acetic  acid ;  or,  if  this  can  not  be  pro- 
cured, with  ordinary  vinegar.  The  intense  smarting  is  soon  controlled  by  the  application  of  cold 
water.  After  this  the  part  is  dried  with  a  towel.  The  dry  but  flexible  eschar  produced  by  the 
union  of  the  acid  with  the  exposed  tissues  gives  excellent  protection,  under  which  the  wound 
heals  without  reaction  or  suppuration.  The  great  advantage  of  this  form  of  treatment  will  be 
especially  appreciated  by  physicians,  as  the  eschar  is  insoluble,  and  the  injured  or  chapped  hands 


12  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

treated  in  this  niaiiner  can  be  waslied  repeatedly  without  compromising  repair  or  risking  new 
infection  by  contact  with  pus. 

More  extensive  burns  or  denudations  are,  within  reasonable  limits,  also 
adapted  to  the  exsiceative  treatment.  However,  to  prevent  injury  of  the 
granulations  at  change  of  dressings,  due  to  their  matting  into  the  meshes 
of  the  gauze,  protecting  the  burned  surface  by  a  layer  of  rubber  tissue  will 
be  found  very  useful  and  commendable.  But  the  larger  the  absorbing  sur- 
face, the  more  caution  is  needed  in  the  use  of  iodoform. 

h.  Chemical  Sterilization^  combined  with  Exsiccation.  Dry 
Dressings. — In  extensive  injuries  or  large  operation  wounds  the  amount 
of  oozing  is  generally  so  large  that  dusting  alone  will  not  suffice  to  control 
decomposition.  Besides  the  j^atieut's  person,  the  bedding  or  splints  will  be 
uncomfortably  soiled ;  hence  it  is  necessary  to  provide  a  receptacle  for  the 
absorption  of  the  secretions.  For  this  purpose  absorbent  dressings  are  used 
that  have  been  rendered  ase]3tic  by  saturation  with  a  chemical  germicide  : 
iodoform,  corrosive  sublimate,  or  carbolic  acid.  A  small  surplus  of  the 
chemical  used  will  suffice  to  prevent  decomposition  of  the  absorbed  serum 
or  blood.  No  impervious  covering  (Mackintosh)  should  be  used  on  the 
outside  of  the  dressing,  as  the  free  admission  of  dustlessair  is  desirable. 
It  will  hasten  the  exsiccation  of  the  absorbed  secretions,  and  thus  insure 
the  protective  action  of  the  dressings,  even  if  the  chemical  employed  become 
evaporated  or  inert.  As  evaporation  of  the  deepest  parts  of  the  dressing — 
those  nearest  the  skin  and  farthest  from  the  surface — is  the  most  difficult, 
and  is  made  still  more  difficult  by  their  greater  saturation  with  serum,  a 
few  layers  of  iodoformized  gauze  placed  immediately  over  the  line  of  union 
will  be  of  very  great  service  in  hastening  exsiccation.  These  are  covered 
with  an  ample  mass  of  dressings  impregnated  with  corrosive  sublimate, 
wliich  are  held  down  with  a  roller  bandage. 

This  is  the  method  of  dressing  most  commonly  resorted  to  nowadays, 
and  has  been  found  the  most  simple  and  effective  by  the  majority  of  modern 
surgeons. 

c.  Schede's  Modification  of  the  Dry  Dressing,  favoring  the 
Organization  of  the  Moist  Blood-Clot. — There  is  a  considerable  num- 
ber of  cases  where  extensive  loss  of  substance  consequent  upon  an  injury 
or  an  operation  precludes  approximation  of  the  walls  of  the  wound,  and 
renders  healing  by  primary  adhesion  impossible.  In  these  cases  a  blood- 
clot  forms  and  fills  up  the  defect  soon  after  the  injury  or  the  operation. 
In  an  aseptic  wound  this  blood-clot  serves  a  highly  useful  purpose  in  pro- 
tecting the  raw  surfaces,  preserving  their  vitality,  provided  that  the  integ- 
rity of  this  blood-clot  be  again  protected  from  exsiccation  on  one  and  from 
putrefaction  on  the  other  hand.  If  this  condition  is  fulfilled,  granulations 
will  gradually  consume,  as  it  were,  the  blood-clot ;  and,  by  the  time  the  clot 
disappears,  cicatrization  will  be  completed.  When  healing  under  the  moist 
blood-clot  is  aimed  at,  the  dressings  will  have  to  be  arranged  as  follows  : 
Immediately  over  the  wound  is  laid  a  suitably  trimmed  ])iece  of  fine  rubber 
tissue,  previously  well  soaked  in  carbolic  solution,     it  should  just  overlap 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  13 

the  edges  of  the  wound.  Tliis  is  covered  with  a  layer  of  iodoformed  gauze, 
and  the  whole  is  well  enveloped  in  an  ample  covering  of  dry  corrosive  sub- 
limate gauze.  The  outer  dressings  will  absorb  and  render  innocuous  the 
surplus  of  blood  and  serum  ;  the  film  of  rubber  tissue  will  preserve  the 
underlying  clot  in  a  moist  condition. 

Note. — Tissues  of  low  vascularity,  as  bone,  fasciae,  and  tendons,  will  certainly  undergo 
superficial  or  deep-going  necrosis  if  exposed  to  evaporation,  even  if  asepsis  be  rigidly  preserved. 

Case. — George  Braun,  German  Hospital,  aged  sixty-six.  Rodent  ulcer  of  the  nose.  Feb. 
19,  1S86. — Extirpation  of  diseased  parts  followed  at  once  by  partial  rhinoplasty.  Sutured  parts 
dusted  with  iodoform.  Large  defect  on  forehead  (the  flap  including  periosteum)  inadvertently 
covered  with  iodoform  gauze,  without  interposition  of  rubber-tissue  protective.  When  the 
dressings  were  removed  ten  days  later,  no  suppuration  was  found,  but  the  surface  of  the  frontal 
bone  was  seen  to  be  exposed  (no  blood-clot),  and  very  dry.  After  four  weeks  the  first  sparse 
granulations  were  observed  sprouting  out  of  the  denuded  bone,  which  eventually  became  cica- 
trized over  in  the  fall  of  the  same  year.  Had  the  protective  not  been  omitted,  rapid  cicatriza- 
tion would  have  been  secured. 

cl.  Simple  Chemical  Sterilization.  Moist  Dressuvtgs. — A  moder- 
ately moist  condition  of  the  outer  dressings  is  very  favorable  to  rapid  ab- 
sorption. This  fact  is  parallel  with  the  phenomenon  seen  if  a  thoroughly 
dry  sponge  is  thrown  on  water.  It  will  not  absorb  rapidly  and  sink,  but, 
on  the  contrary,  will  float  on  the  surface  for  a  considerable  period  of  time. 
But  moisten  this  sponge  first  thoroughly,  then  squeeze  it  out  completely, 
and  then  throw  it  into  water,  and  it  will  at  once  become  filled  and  sink. 
Where  rapid  absorption  is  desirable,  as  in  the  presence  of  septic  or  fetid 
discharges,  and  where  clogging  of  the  drainage-holes  by  inspissated  secre- 
tions is  to  be  avoided,  dry  dressings  will  be  advantageously  replaced  by  a 
moist  dressing.  By  applying  a  piece  of  impermeable  material  to  the  out- 
side of  the  well-moistened  dressings,  evaporation  and  exsiccation  will  be 
prevented,  and  the  dressings  will  remain  in  a  moist  condition  for  an  indefi- 
nite period  of  time. 

Rubber  tissue  (not  rubber  sheeting)  is  an  excellent  and  cheap  substitute 
for  Lister's  '^Mackintosh"  and  his  "protective."  It  can  be  had  in  all 
rubber  stores.  A  rather  stout  quality  is  the  best  article,  as  it  is  not  apt  to 
tear,  and  can  be  repeatedly  used  as  the  outer  covering  of  moist  dressings. 
It  always  forms  the  outermost  layer  of  what  is  called  throughout  this  book  a 
^^ moist  dressing.''''  Oiled  silk,  well  soaked  in  carbolized  lotion,  is  a  toler- 
able substitute  for  rubber  tissue.  Another  substitute  is  waxed  paper,  or 
''tracing  paper."  A  piece  of  stout,  brown  paper,  such  as  is  used  by  shop- 
keepers for  packing,  well  soaked  in  grease,  preferably  tallow,  will  answer 
on  a  pinch.  If  none  of  these  articles  can  be  had,  frequent  moistenings  of 
the  dressings  will  have  to  be  employed  in  order  to  prevent  evaporation. 
One  or  more  teaspoonfuls  of  carbolic  or  mercurial  lotion  instilled  into  the 
dressings  every  half-hour  or  so  will  have  the  desired  effect.  This  form  of 
moist  wound-treatment  was  very  extensively  employed  by  the  author  in  his 
seven-years'  service  at  the  German  Dispensary,  and  has  been  found  so  satis- 
factory botli  to  patients  and  surgeons  that  it  is  still  the  standard  form  of 

moist  dressing  used  at  that  institution. 

4 


14 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


(2)  Preparation  of  Dressings. 

a.  Gauze. — Gauze,  called  in  the  trade  cheese-cloth,  or  tobacco-cloth, 
forms  undoubtedly  the  most  convenient  material  for  wound-dressings.  It 
is  cheap,  can  be  bought  everywhere,  absorbs  well,  is  soft  and  pliable,  and 
can  be  easily  prepared  for  use  by  every  practitioner.     For  hospital  pur- 

14  in. 


UPPEFI     AND 
14  in.  1  LOWER    EXTREMITY. 
HIPJOINT. 
TRUNK. 


HERNIOTOMY, 
SCROTUM. 


14  ill. 
24  in. 


SHOULDER  \^     UOINT. 
AXILLA. 

ANKLE  A  JO/ Ayr. 


AIECK  AND  ARM. 


19  in. 


AXILLA 


AND    BREAST. 


2H  in. 


28  in. 


EXSECTION   OF 


SHOULDER     JOINT. 


19  in. 


19  in. 


LOWER     EXTREMITIES. 


AMPUTATION 


DF   THIGH. 


28  in.  28  in. 

Fig.  1.— Patterns  for  various  drcssin,£fs,  modified  from  Ncuber. 

poses,  moss  or  peat  dressings  in  the  shape  of  cushions  or  bags  are  more 
convenient.  In  the  practice  of  the  country  physician,  however,  they  are 
out  of  the  question. 


ASEPTIC  WOUNDS— ASEPTIC    TREATMENT.  15 

(a)  Cori'osive  Sublimate  Gauze. — The  raw  gauze  is  treated  as  follows  : 
To  free  it  of  its  oily  contents,  and  thus  to  make  it  more  absorbent, 
twenty-five  yards  of  the  fabric  are  boiled  for  an  hour  in  a  wash-kettle  filled 
with  sufficient  water  to  cover  the  material,  to  which  should  be  added  two 
pounds  of  washing-soda  or  a  pint  of  strong  lye.  After  this  the  stuff  is 
washed  out  in  cold  water,  passed  through  a  clothes-wringer,  and  immersed 
in  a  sufficient  quantity  of  a  1:  1,000  solution  of  corrosive  sublimate  for 
twenty-four  hours,  then  passed  again  through  a  clothes-wringer,  dried,  and 
put  away  in  a  well-covered  glass  jar  until  required  for  use. 

The  fabric  is  so  folded  by  the  manufacturer  that  each  fold  is  just  one 
yard  long.  It  is  best  to  divide  the  twenty-five  yards  into  segments  of  about 
six  yards  each,  which  can  be  again  folded  by  the  surgeon  into  large  or  small, 
square,  oblong,  or  narrow  compresses  to  suit  each  individual  case.  If  a 
long  time  has  elapsed  since  the  preparation,  reimpregnation  with  a  1 :  1,000 
solution  of  corrosive  sublimate  is  advisable  before  use. 

Note. — In  a  small  proportion  of  cases,  contact  with  corrosive-sublimate  dressings  will  cause 
an  angry-looking  dermatitis,  which  at  the  first  blush  very  closely  resembles  erysipelas.  The 
absence  of  fever  and  sickness,  the  exact  limitation  of  the  rash  by  the  extent  of  the  dressings, 
will  soon  disperse  possible  doubts.     Profuse  application  of  vaseline 

or  some  other  bland  ointment  will  readily  dispose  of  the  irritation.  ^g__r!^  .  .  '7^'^^ 
The  strength  of  the  impregnation  should  be  then  also  reduced  by  \^^^^^^^^^^^ 
washing  the  gauze  in  water.     If  it  should  be  found  that  mercury  is  ^^^^^^^^^^T 

not  borne  at  all,  it  should  be  substituted  by  carbolic-acid  solution  or  ^^^^p^^^^^M 

Thiersch's  boro-salicylic  lotion.  ^^^^^^^§ 

llllli  iiiiB 

{h)  lodoformized    Gauze. — The   moist,   absorbent  IBtieJII'H 

gauze  is  evenly  sprinkled  with  iodoform  powder  from  11       ''(  lljB 

a  pepper-box,  or  the  author's  iodoform  duster,  well  It         Ifl 

rubbed  into  the  meshes  by  hand,  and  then  put  away  i  li     |i{|ilH 

in  a  wide-mouthed  bottle.  |||||j  jj||i|||H 

Roller  bandages  are  made  out  of  corrosive-sublimate  ^^^^^^J 

gauze.  ^*«CEn3a332nBSB>»^ 

Fig.   2.— The  author's 

Note. — Roller  bandages  made  of  a  starched  fabric  known  as  iodoform     duster,      with 

,,.,.„„              ,.   .       „                         .  ,   .               ,     .  screw  cap  and  removable 

cnnolme,    or     crown-hnmg,    are  very  useful  m  corapletmg  every  bottom  tor  replenishino-. 

dressing.     They  are  moistened  in  water,  and  applied  over  the  dry 

roller-bandage.     They  soon  become  stiff  again,  and  make  a  very  compact  and  neat  dressing, 

that  will  not  shift  easily.     The  stuff  is  the  same  that  is  used  extensively  for  plaster-of-Paris 

bandages. 

In  emergencies  various  substances  of  absorbent  qualities  can  be  utilized 
as  dressings  ;  such  are,  for  instance,  cotton,  moss,  and  sawdust. 

b.  Absoebent  coTTOisr,  or  coMMOisr  cottojst  battii^g,  well  soaked  in 
corrosive-sublimate  solution,  then  wrung  out,  will  make  a  tolerable  dress- 
ing. Its  drawbacks  are  that  it  packs  and  gets  hard  and  lumpy,  but,  prop- 
erly used,  it  will  answer  every  practical  purpose.  Care  should  be  taken 
not  to  tear  the  cotton  into  irregular  masses.  After  unrolling  it,  suitably 
large,  square  pieces  should  be  cut  off  with  the  scissors  ;  these  pieces  should 
be  folded,  then  soaked  in  the  lotion,  squeezed  out  hard,  and  unfolded  again. 


16  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

thus  preserving  their  shape  and  uniform  tliickness.     Two  or  more  of  these 
pieces  laid  one  over  another  will  make  a  very  passable  dressing. 

Case. — Michael  B.,  aged  sixty -three,  sustained,  early  in  the  morning  of  November 
13,  1883,  a  compound  fracture  of  the  left  elbow-joint.  He  was  put  to  bed,  and,  under 
the  advice  of  the  family  attendant,  applications  of  cold  water  were  made  to  the  injured 
part.  Twelve  hours  after  the  injury,  the  author  found  a  Y-shaped  fracture  of  the  lower 
end  of  the  humerus,  the  conical  sharp  point  of  the  upper  fragment  protruding  through 
a  small  wound  above  the  olecranon.  The  joint  was  tilled  with  a  large  clot,  and  some 
oozing  from  the  perforation  was  noticed.  The  edges  of  the  perforation  wound  were 
snugly  fitting  around  the  protruding  bone,  and  during  the  subsequent  manipulations 
good  care  was  taken  not  to  allow  the  bone  to  slip  back.  Not  having  been  informed 
of  the  nature  of  the  injury,  the  author  arrived  unprepared  at  the  patient's  bedside.  The 
case,  however,  did  not  br.ook  delay,  hence  everything  had  to  be  extemporized.  Sev- 
eral ounces  of  a  ten-per-cent  alcoholic  solution  of  corrosive  sublimate  and  a  little  iodo- 
form were  ordered  from  the  nearest  druggist,  and  at  the  same  time  several  bundles  ot 
common  cotton  batting  were  procured.  Soon  plenty  of  a  1 :  1,000  corrosive-sublimate 
solution  was  ready,  in  which  square  pieces  of  cotton  were  soaked  as  described.  The 
patient's  poverty  compelled  an  economical  management  of  affairs.  An  old  but  clean 
bed-sheet  was  ripped  up  into  roller-bandages,  which  were  likewise  impregnated.  This 
done,  soap  and  hot  water  were  applied  to  the  elbow,  and  the  skin  was  shaved  clean  all 
around,  but  especially  near  the  perforation.  This  was  followed  by  a  vigorous  rubbing 
off  of  the  skin  and  protruding  bone  with  the  mercuric  lotion,  which  at  the  same  time 
was  copiously  poured  over  the  region  of  the  elbow  from  a  pitcher.  After  this,  reduction 
of  the  protruding  bone  and  adjustment  of  the  fragments  by  extension  of  the  arm  was 
effected.  The  size  of  the  perforation-hole  at  once  became  much  smaller.  In  order  to 
provide  some  drainage,  a  small  fillet  of  cotton,  well  dusted  with  iodoform,  was  inserted 
into  the  cutaneous  part  of  the  outer  wound,  which  was  also  liberally  dusted.  Over 
this  were  placed  four  layers  of  cotton  pads,  which  were  snugly  bandaged  to  the  limb. 
Two  lateral  splints,  made  of  a  pasteboard  box,  secured  the  extended  position,  in  which 
the  arm  was  suspended  from  a  nail  in  the  ceiling.  The  temperature  never  rose  alove 
100°  Fahr.  Nov.  19. — The  dressings  were  removed.  The  swelling,  due  to  the  effusion 
of  blood,  had  disappeared  to  a  great  extent.  Oozing  had  ceased;  no  suppuration. 
The  fillet  of  cotton  was  withdrawn,  and  the  arm  was  put  up  in  s  plaster-of-Paris  splint 
flexed  at  a  right  angle.  Passive  motion  was  commenced  on  removal  of  the  splint,  four 
weeks  after  the  injury.  Ultimate  result  was  ascertained  in  October,  1884:  Flexion 
was  normal;  extension  could  not  be  carried  beyond  140°. 

c.  Sawdust. — With  a  view  to  the  occasional  impossibility  of  procuring 
any  of  the  common  dressing  materials  in  times  of  war  or  some  other  public 
calamity,  the  author  has  tested  the  efficacy  of  sawdust  as  a  dressing  during 
his  service  at  Mount  Sinai  Hospital,  extending  from  August  1,  1883,  till 
February  1,  1884.  Clean  pine,  spruce,  or  hemlock  sawdust  was  impreg- 
nated with  a  1  :  1,000  solution  of  corrosive  sublimate  for  twenty-four  hours  ; 
then  it  was  spread  on  sheets  of  muslin  to  dry,  and  finally  was  inclosed  in 
different-sized  bags  made  of  cliecse-cloth  gauze.  To  prevent  the  shifting  of 
the  sawdust,  a  thin  layer  of  wood-shavings,  called  by  the  trade  "excelsior," 
was  first  inserted  into  the  open  bag  ;  then  a  proportionate  quantity  of  saw- 
dust was  evenly  strewed  into  the  meshes  of  the  "excelsior,"  and  then  the 
bag  was  closed  by  stitches  made  with  threads  soaked  in  mercuric  lotion. 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT.  17 

The  thickness  of  the  bags  varied,  according  to  their  size,  from  one  to  two 
inches.  After  the  wound  was  drained  and  sewed,  some  iodoform  gauze 
was  placed  next  to  it ;  then  came  one,  two,  or  more  smaller  bags,  and  on 
top  a  large  bag,  the  whole  being  snugly  fastened  with  roller  bandages. 

Aside  from  the  trouble  of  preparing  the  bags,  they  were  found  very  con- 
venient in  applying  and  quite  efficient  in  absorbing  blood  and  serum,  and 
preventing  decomposition. 

d.  Moss. — The  different  species  of  sphagnum,  coating  the  surface  of  peat- 
bogs and  the  trunks  of  dead  trees  in  our  northern  forests,  are  excellent 
material  for  making  dressing-bags.  On  account  of  its  cheapness,  small 
weight,  elasticity,  and  great  absorbing  power,  moss  has  displaced  other 
dressings  at  almost  all  of  the  surgical  clinics  of  Germany.  Its  preparation 
is  very  simple.  It  has  to  be  gathered  with  some  care — that  is,  with  no  ad- 
mixture of  the  soil.  After  being  dried,  it  is  imj^regnated  with  corrosive 
sublimate,  inclosed  in  gauze  bags,  and  is  ready  for  use.  Moss-bags  are  in 
daily  use  at  the  German  Hospital  since  1884,  and  can  not  be  praised  enough 
both  for  their  handiness  and  effectiveness.  But,  like  other  similar  dress- 
ings, they  are  not  adapted  to  the  needs  of  the  general  practitioner,  and  will 
find  their  principal  employment  in  hospital  practice. 


m.  PRACTICAL  APPLICATION  OF  RULES. 

1.  In  operating". — In  order  to  gain  a  coherent  idea  of  the  practical  work- 
ings of  the  aseptic  apparatus,  we  shall  now  rehearse  all  the  steps  of  a  well- 
conducted  operation. 

Assuming  that  a  cancerous  breast  is  to  be  removed  in  the  rooms  of  the 
patient,  it  is  first  necessary  to  select  a  suitable  person  to  act  as  nurse.  Her 
duty  is  to  administer  a  laxative  the  day  before  the  operation,  and  to  care- 
fully scrub  with  soap  and  brush  the  patient's  breast,  corresponding  shoulder, 
and  axillary  sjaace  on  the  day  preceding  and  on  the  day  of  the  operation. 
A  clean,  well-lighted  room  is  selected,  out  of  which  all  unnecessary  furniture, 
hangings,  etc.,  should  be  removed.  A  bare,  well-scrubbed  floor  is  prefera- 
ble to  a  carpet.  One  or  two  narrow  kitchen-tables,  covered  with  a  quilt 
and  provided  with  a  straw  pillow,  will  make  a  capital  operating-table.  A 
piece  of  rubber  cloth  (3x4  feet)  is  placed  over  the  quilt,  and  a  clean  sheet 
is  laid  on  top.  The  nurse  provides  soap,  nail-brush,  plenty  of  hot  and  cold 
water,  and  towels.  The  operator  and  his  assistants  arrive  at  least  a  half- 
hour  before  the  appointed  time  of  the  operation.  Everybody's  hands  are 
washed  in  hot  water  with  soap  and  brush.  The  necessaries  are  now  un- 
packed and  arranged,  and  the  solutions  of  carbolic  acid  and  corrosive  sub- 
limate are  mixed,  for  which  purpose  six  or  eight  well-cleansed  quart  bottles 
should  be  held  in  readiness  by  the  nurse.  A  fountain  syringe  is  filled  with 
sublimate  solution,  and  suitably  suspended  from  a  nail  or  chandelier  near 
the  operating-table.  A  new  pail  or  bucket  is  filled  with  hot  water  for  rins- 
ing the  blood  out  of  the  sponges  ;  alongside  of  it  is  placed  a  basin  filled  with 


18  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  three-per-cenfc  solution  of  carbolic  acid  for  the  recei^tion  of  the  cleaned 
sponges,  from  which  they  ougiit  to  be  handed  to  the  assistants  by  the  nurse. 
Two  more  japanned  tin  basins  are  filled  with  a  corrosive-sublimate  solution, 
and  placed  on  chairs  to  the  right  and  left  of  the  operating-table  for  the 
occasional  rinsing  of  the  hands  of  the  operator  and  assistants.  The  in- 
struments are  arranged  on  an  adjacent  table  in  a  certain  order,  which,  to 
prevent  confusion  and  ill-temper,  should  be  rigidly  adhered  to  during  the 
entire  operation. 

Note. — The  author  has  found  that  it  is  very  convenient  to  be  independent  of  the  patient's 
resources,  as  far  as  the  necessary  vessels  for  sponges  and  instruments  are  concerned.  A  nest 
of  four  good-sized,  flat-bottomed  block-tin  wash-basins,  six  tin  soup-basins  (six  inches  diameter), 
and  four  tin  bake-pans,  will  serve  every  purpose,  and  the  small  expense  will  be  abundantly 
repaid  by  the  cleanliness  and  sense  of  comfort  that  will  result.  This  small  inventory  will  keep 
long,  and  may  serve  again  and  again  at  many  operations. 

All  vessels  are  wiped  clean.  The  knives,  sharp  and  blunt  retractors, 
scissors,  anatomical,  mouse-tooth,  and  dressing  forceps,  probes,  and  grooved 
director  should  be  put  into  one  pan  with  carbolic  lotion  ;  all  the  artery  for- 
ceps by  themselves  into  another  one.  Between  the  two  pans  is  placed  a 
third  one,  filled  with  hot  water,  in  which  all  the  instruments  not  in  actual 
use  should  be  rinsed  free  from  blood  before  being  returned  to  the  carbolic 
lotion.  This  will  keep  them  and  the  carbolic  lotion  clean  and  bright  all 
the  while,  and  no  time  will  be  lost  in  hunting  for  them  in  the  bottom  of  a 
turbid  pool  of  soiled  carbolic  solution.  In  a  smaller  tin  basin,  ligatures,  in 
another  one  needles,  are  arranged,  threaded  with  fine  (No.  0)  and  coarser 
(No.  1  or  2)  catgut.  A  third  small  basin  will  hold  the  drainage-tubes  and 
a  number  of  safety-pins. 

The  dressings  are  now  attended  to.  Eight  or  ten  small  (6x8  inches),  and 
just  as  many  large  (19x28  inches),  compresses  of  gauze  are  cut,  care  being 
taken  not  to  make  the  dressings  too  scanty,  as  an  ample  first  dressing  may 
save  the  trouble  of  many  subsequent  dressings.  The  best  rule  is  to  let  the 
outermost  compresses  overlap  the  wound  on  all  sides  b  v  at  least  eight  inches. 
To  this  should  be  added  a  sufficient  number  of  strips  of  iodoformed  gauze, 
three  or  four  rather  wide  gauze  roller-bandages,  and  the  same  number  of 
starched  or  crinoline  roller-bandages.  All  this  should  be  wrapped  in  a 
clean  towel  and  laid  aside  in  a  secure  place  until  needed. 

All  this  having  been  attended  to,  anaesthesia  may  commence  in  an  adja- 
cent room.  The  anaesthetizer  should  be  provided  with  ether  and  a  cone,  a 
tin  basin  for  the  reception  of  ejecta  in  case  of  vomiting,  a  towel,  a  hypo- 
dermic syringe,  a  wide-mouthed  bottle  with  morphine  solution  for  injections 
in  case  anaesthesia  be  imperfect,  a  similar  bottle  with  whisky  to  be  used  in 
case  of  heart-failure  ;  finally,  with  a  dressing-forceps  and  gag  for  withdraw- 
ing the  tongue  if  it  should  sink  back  on  the  epiglottis. 

The  anaesthetized  patient  is  placed  on  the  operating-table,  and  the  parts, 
being  exposed,  are  freely  soaped  and  shaved.  After  this  a  piece  of  rubber 
cloth  (3  X  4  feet)  is  so  placed  over  the  patient's  body  as  to  leave  exposed 
only  the  field  of  operation.     Now  the  parts  are  well  rubbed  otf  with  a  towel 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT. 


1!) 


dipped  in  corrosive-sublimute  solution  and  freely  irrigated,  and  a  number 
of  clean  towels  wrung  out  of  the  same  solution  are  suitably  spread  around 
the  field  of  operation,  protecting  the  operator  and  assistants  against  contact 
with  the  clothing  or  body  of  the  patient,  and  providing  for  a  clean  place 
where  instruments  or  sponges  may  be  laid  down  for  a  moment  if  necessary. 
The  end  of  a  wet  towel  is  tucked  under  the  breast  and  armpit  of  the  side 
to  be  operated  on,  and  is  hung  over  the  edge  of  the  table  in  such  a  manner 
as  to  conduct  the  blood  and  irrigating  fluid  into  a  bucket  placed  on  the  floor 
underneath.  It  serves  as  a  drip-cloth.  Every  assistant  should  strictly  attend 
to  the  duty  allotted  to  him,  and  not  meddle.  All  unnecessary  talk  should 
cease,  and  the  work  proceed  in  an  orderly  manner.  The  first  assistant 
should  keep  his  eyes  open,  and  know  and  aid  the  operator's  intentions.  He 
should  be  alert,  but  not  over-zealous. 


Fig.  S. — Patient  made  ready  for  amputation  of  maimua. 


The  anaesthetizer  must  take  good  care  that,  in  case  of  vomiting,  no  ejecta 
are  thrown  on  the  wound  or  its  vicinity.  Towels  soiled  by  vomit  should 
be  at  once  replaced  by  clean  ones. 

Now  the  parts  are  distributed.  The  trustiest  man  serves  as  first  assist- 
ant over  against  the  operator  ;  a  younger  physician  at  the  left  of  the  operator 
is  second  assistant,  and  irrigates  or  helps  as  need  may  require  ;  another 
physician  takes  charge  of  the  instruments  and  ligatures,  and  the  nurse 
attends  to  the  sponges,  and  keeps  in  readiness  "  sublimated  "  and  dry  towels 
and  a  pitcherful  of  corrosive-sublimate  solution. 

Aprons  are  donned,  everybody's  hands  are  finally  scrubbed  with  soap 
and  brush,  rinsed  in  mercuric  solution,  and  the  operation  begins. 


20  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Note. — The  employment  of  copious  irrigation  during  operations  requires  measures  for  pro- 
tecting the  person  and  clothing  of  the  surgeon  against  the  influence  of  the  chemicals  commonly 
used.  An  ample  apron,  made  of  light  rubber  sheeting,  and  reaching  from  the  chin  to  the  toes, 
is  most  convenient,  and  can  be  easily  cleaned.  The  surgeon's  shoes  may  be  protected  by  a  pair 
of  light  rubbers.  However,  they  are  apt  to  sweat  the  feet.  The  author  overcame  this  draw- 
back by  the  use,  at  the  hospital,  of  wooden  pattens  (French  sabots)  worn  over  the  shoes.  They 
are  donned  and  doffed  without  the  aid  of  the  hands,  and  keep  the  feet  warm  and  dry,  and  can 
be  bought  at  75  Essex  Street,  New  York. 

Ill  removing  the  breast  and  contents  of  the  axilla,  hemorrhage  should 
be  carefully  attended  to  by  ligaturing  every  bleeding  vessel  with  catgut. 
Having  removed  the  diseased  parts,  the  wound  is  carefully  irrigated,  each 
recess  being  attended  to  in  succession ;  drainage  and  sutures  are  applied. 
The  projecting  end  of  the  drainage-tube  cut  off  "flush  "  is  transfixed  with 
a  safety-pin,  the  wound  is  once  more  irrigated  through  the  tube  so  as  to 
clear  it  of  clots,  and  the  clots  and  irrigating  fluid  are  removed  from  the 
wound  by  gentle  pressure  exerted  with  a  sponge  or  two,  lodoformed  gauze 
strips  are  next  placed  along  the  suture  and  around  the  drainage-tube,  pass- 
ing under  the  safety-pin,  and  a  few  pads  of  gauze  are  held  pressed  against 
the  wound  while  the  patient  is  slightly  raised  to  cleanse  her  back  and  face 
and  the  table  from  blood.  The  soiled  towels  are  replaced  by  dry  ones,  and 
the  dressing  completed  by  applying  as  many  gauze  compresses  as  required. 
These  are  fastened  rather  tightly  with  gauze  bandages,  the  other  breast  and 
arm-pits  being  first  padded  with  absorbent  cotton.  A  large,  square  piece  of 
absorbent  cotton,  somewhat  overlapping  the  dressings,  is  next  applied,  and 
snugly  held  down  by  crinoline  roller-bandages ;  the  corresponding  arm  is 
included  by  the  bandage  or  is  placed  in  a  sling  ;  the  patient  is  brought  to 
bed,  and  an  opiate  is  administered. 

2.  Change  of  Dressings. — In  most  cases  where  the  rules  above  given 
are  conscientiously  and  intelligently  observed,  no  fever  will  follow  the 
operation.  After  the  effects  of  the  anaesthesia  are  over,  the  patients  will 
be  found  cheerful  and  contented,  feeling  no  pain  or  siciiness,  their  only  com- 
plaint being  the  tightness  of  the  bandage,  which  they  will  soon  learn  to 
bear.  The  temperature  will  range  during  the  first  three  days  at  about  100° 
Fahr. ;  after  that  it  will  sink  to  the  normal  standard.  Sometimes,  especially 
if  the  drainage  is  not  properly  placed,  and  some  serum  or  a  blood-clot  is 
retained  in  the  wound,  the  thermometer  will  indicate  from  100°  to  103° 
Fahr.  As  long,  however,  as  the  patient  is  cheerful,  and  does  not  feel  sick 
with  headache  and  general  dejection,  as  there  is  no  sharp,  throbbing  pain 
about  the  wound,  or  some  other  grave  disturbance  of  the  local  or  general 
comfort,  no  alarm  need  be  felt.  In  these  cases  we  have  to  deal  with  an  ele- 
vation of  temperature  benign  in  character,  and  identical  with  the  harmless 
fever  observed  after  almost  every  simple  fracture.  It  is  due  to  the  absorption 
of  the  extravasated  blood  or  lymph,  bland  and  harmless  on  account  of  the 
absence  of  putrefactive  changes.     This  is  Volkmann's  "aseptic  fever." 

The  temperature  soon  becomes  lowered,  appetite  reappears,  and  the  dress- 
ings need  not  be  disturbed. 


ASEPTIC  WOUNDS— ASEPTIC  TREATMENT. 


21 


Should,  on  tlie  other  hand,  the  i)atient  complain  of  chilliness,  headache, 
sickness,  general  dejection,  and  drawing  pains  in  the  limbs,  or  persistent 
and  increasing  pain  about  the  wound,  the  thermometer  indicating  at  the 
same  time  a  high  or  only  a  moderate  elevation,  the  dressings  should  at  once 
be  removed,  and  a  search  instituted  for  the  cause  of  the  disturbance. 

Previous  to  this  a  new  dressing  should  be  prepared  similar  to  the  one 
to  be  removed.  This  and  a  tin  pan  containing  carbolic  lotion,  with  a  dress- 
ing-forceps, anatomical  forceps,  scissors,  scalpel,  grooved  director,  and  a 
piece  of  dra.inage-tube,  together  with  another  vessel  holding  a  few  small 
pads  of  cotton  wrung  out  of  the  same  solution,  should  be  ])laced  on  a  small 
table  near  the  bed.  An  irrigator  filled  Avith  loarm  carbolic  or  mercuric 
lotion  should  be  suspended  from  the  bedpost  or  a  nail,  and  a  pail  for  the 


Fig.  4. — Change  of  drussiuii's  al'ter  amputatiou  of  the  thigh. 

reception  of  the  soiled  dressings  should  be  at  hand.  A  piece  of  rubber  cloth 
covered  with  a  draw-sheet  and  spread  under  the  patient's  back  will  protect 
the  bed,  and  a  ])us-basin  or  square  tin  pan  held  alongside  of  the  patient's 
thorax  will  receive  the  irrigating  fluid. 

After  this  the  turns  of  the  roller-bandage  are  cut  through  without  jar, 
and  the  outer  layers  of  the  dressing  are  gradually  removed.  As  the  deeper 
parts  are  being  raised,  irrigation  should  commence,  in  order  to  moisten  the 
gauze  and  aid  in  its  gentle  removal.  Care  should  be  taken  not  to  disturb 
the  drainage-tubes.  After  the  removal  of  the  soiled  dressings,  the  physi- 
ciari's  hands  should  he  carefully  cleansed  before  touching  any  part  of  the 
wound.  While  the  irrigating  stream  is  playing,  the  vicinity  of  the  wound 
is  gently  wiped  with  a  small  pad  of  moistened  cotton,  in  order  to  remove 
clots  of  blood  or  fibrin  that  can  not  be  dislodged  by  irrigation. 
5 


22  RULES   OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 

If  the  edges  aud  vicinity  of  the  wound  look  normal,  the  skin  pale,  not 
swollen,  and  not  painful  to  touch,  it  should  be  forthwith  redressed.  A  care- 
ful physical  examination  of  the  internal  organs  will  then  certainly  reveal, 
as  the  cause  of  the  fever,  some  internal  complication,  as,  for  instance,  ^aneu- 
monia,  or,  at  any  rate,  some  newly  developed  or  overlooked  disorder  inde- 
pendent of  the  wound. 

If  the  aseptic  measures  employed  were  insufficient,  the  edges  of  the 
wound  will  be  found  swollen,  reddened,  and  painful ;  the  wound  will  have 
lost  its  aseptic  character,  and  is  the  seat  of  a  septic  process  ending  in  sup- 
puration. Prompt  action  is  required  to  limit  the  inevitable  destruction  of 
tissue,  and  to  check  the  further  poisoning  of  the  system. 

From  this  moment  on,  aseptics  must  give  way  to  antiseptics  ;  prevention 
having  failed,  curative  measures  must  step  in  to  eliminate  the  mischief 
that  might  have  been  prevented  by  the  exhibition  of  more  care,  attention, 
or  skill. 

The  therapy  of  septically  infected  or  suppurating  wounds  will  be  treated 
in  the  following  chapter. 

In  case  that  the  course  of  the  healing  of  the  wound  is  correct,  as  indi- 
cated by  the  absence  of  local  or  general  disturbance,  the  first  dressing  may 
remain  unchanged  for  from  seven  to  forty  days.  Flesh-wounds  should  be 
dressed  on  the  seventh  day,  as  it  is  desirable  to  remove  the  drainage-tubes 
and  sometimes  the  stitches.  The  finer  catgut  sutures  will  generally  be 
absorbed  by  this  time,  and  their  exposed  part  can  be  simply  wiped  away. 
Where  stout  retention  sutures  were  employed  for  the  approach  of  the  edges 
of  a  wide,  gaping  wound,  they  will  be  found  cutting  through  the  tissues 
by  this  time,  and  quite  useless.  They  should  be  removed,  and  the  stitch- 
holes  dusted  with  iodoform.  According  to  the  completeness  of  the  result, 
the  dressings  will  have  to  be  changed  every  third,  fifth,  or  seventh  day, 
their  bulk  decreasing  with  the  diminution  of  the  secretions.  Finally,  the 
few  granulating  spots  need  only  a  dressing  consisting  of  a  patch  of  some 
unirritant  plaster,  such  as  empl.  cerussae  or  empl.  hydrarg.,  and  an  occasional 
touching  with  nitrate  of  silver,  to  aid  final  cicatrization.  Where  the  opera- 
tion has  involved  parts  of  the  skeleton,  as  in  amputations  of  extremities, 
exsections  of  joints,  necrotomies,  etc.,  the  dressings  have  to  be  left  undis- 
turbed much  longer.  After  exsections  of  the  knee-joint,  for  instance,  where 
bony  ankylosis  is  aimed  at,  the  first  dressing  is  not  removed  without  a  clear 
indication  before  the  thirtieth  or  fortieth  day.  No  patient  should  be  dis- 
charged "cured"  before  cicatrization  is  complete,  as  it  has  happened  that 
such  ''cured"  cases,  left  to  their  own  care,  contracted  erysipelas  the  day 
after  their  discharge,  and  died  of  it. 

Note. — All  the  manipulations  about  a  freshly  agglutinated  wound  should  be  very  deliber- 
ate and  gentle.  In  removing  stitches,  a  forceps  should  gently  raise  the  thread ;  then  it  should 
be  cut  as  close  to  the  stitch-hole  as  possible,  and  lightly  withdrawn.  Drainage-tubes  are 
grasped  at  the  projecting  end,  gently  rotated  to  and  fro  till  they  are  freely  movable,  then  with- 
drawn. Sometimes  it  will  be  found  that  a  painless  fluctuating  swelling  occupies  some  deeper 
part  of  the  wound.     In  these  cases  retention  of  serum  is  generally  caus(;d  by  clogging  of  the 


ASEPTIC  WOUNDS— ASEPTIC   TREATMENT.  23 

drainage-tiil)e  by  a  clot.  On  witlidrawiiig  the  tube,  a  quantity  of  clear  or  turbid  yellowish  serum 
will  escape.  In  these  cases  it  is  good  to  replace  the  cleared  tubing  to  prevent  further  retention, 
and  thus  to  bring  about  contact  of  the  separated  walls  of  the  wound,  which  will  at  once  become 
adherent.     At  the  subsequent  change  of  dressings,  the  tube  can  be  definitively  removed. 

Case. — Mrs.  Clara  G.,  aged  forty-six.  Alveolar  glandular  cancer  of  an  aberrant 
{detached)  lobe  of  the  right  breast.  Tumor  of  the  size  of  a  small  fist,  situated  in  the 
axillary  space  close  to  the  edge  of  the  pectoralis  major  muscle.  It  was  connected  by 
a  stout  pedicle  with  the  adjacent  part  of  the  breast-ghind  proper.  Jan.  16,  1885. — 
Amputation  of  mamma;  total  evacuation  of  axillary  fat  and  glands.  Drainage  by 
counter  opening  made  through  the  latissimus  dorsi  muscle.  Suture  of  tlie  entire  wound 
except  a  part  of  axilla,  where  the  skin  had  been  extensively  removed.  Course  of  heal- 
ing feverless.  Change  of  dressings  on  the  tenth  day.  Primary  union  of  all  the  sutured 
parts.  Axillary  wound  granulating.  Under  the  lower  flap  of  the  breast-wound  a  pain- 
less, soft,  fluctuating  SAvelling  discernible.  By  gently  inserting  a  probe  between  the 
corresponding  edges  of  the  united  wound,  entrance  into  this  sac  was  eflTected,  where- 
upon about  two  ounces  of  a  yellow,  slightly  turbid,  and  very  viscid  se^um  escaped.  A 
small  drainage-tube  was  inserted,  and  the  wound  was  redressed.  Jan.  30th. — Walls 
of  the  cavity  were  found  firmly  adherent.     Tube  removed.     No  suppuration. 

The  interior  of  freshly  healed  wounds  of  normal  appearance  should  never 
be  syringed  ;  the  injection  of  a  strong  jet  of  fluid  is  unnecessary  and  often 
injurious,  as  it  tends  to  separate  tender  adhesions. 

IV.     ASEPTIC    MEASURES    IN    EMERGENCIES. 

Unremitting  attention  to,  and  a  severe  self-discipline  in  always  carrying 
out  the  measures  of  strict  cleanliness  known  to  be  necessary  to  uniform 
success  in  the  management  of  wounds  will  gradually  become,  liowever 
irksome  in  the  beginning,  a  mere  matter  of  accustomed  routine.  As  the 
mind  and  senses  learn  to  exercise  vigilance  without  special  effort,  the  sur- 
geon's results  will  become  more  and  more  gratifying.  His  attention,  freed 
from  the  severe  strain  unavoidable  in  acquiring  command  of  the  detail  of 
a  difficult  business,  will  concentrate  itself  upon  higher  objects,  and  the 
smooth  routine  resulting  from  long  and  severe  training  will  not  divert 
attention  from  the  finer  detail  of  his  special  work. 

It  is  a  great  mistake,  paid  for  by  the  loss  of  limbs  and  lives,  to  believe 
that  the  mastery  of  practical  cleanliness  or  asepticism  can  be  acquired  with- 
out a  clear  comprehension  of  the  principle,  and  without  earnest  and  severe 
training  in  the  handicraft  of  asepticism.  The  wholesome  truth,  that  failure 
of  achieving  primary  union  in  fresh  wounds  is  mainly  and  almost  always 
due  to  one's  own  lack  of  knowledge  and  skill,  and  that  these  attributes  can 
be  secured  only  by  the  exercise  of  great  diligence  and  many,  often  unsuc- 
cessful trials,  should  be  constantly  present  in  our  mind.  Failures  are  bitter 
lessons,  but  their  honest  study  will  inevitably  bring  to  light  the  causative 
deficiencies,  and  will  teach  us  to  avoid  them. 

The  school  for  learning  to  employ  the  principles  of  asepticism  is  open 
to  every  general  practitioner  in  the  treatment  of  the  many  affections  and 
injuries  pertaining  to  minor  surgery.      Mistakes  made  in  the  removal  of  a 


24  RULES  OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 

wen  or  the  treatment  of  an  incised  wound  of  the  hand  are  easily  found  out 
and  easily  corrected.  They  carry  much  and  sometimes  more  instruction 
than  a  large  operation.  It  is  wicked  to  attempt  to  learn  the  first  lessons  of 
aseptic  surgery  in  laparotomy,  when,  possibly,  the  surgeon's  experience  is 
bought  with  the  life  of  his  trusting  patient.  The  attempt  of  removing  an 
ovarian  tumor,  for  instance,  should  be  permitted  only  to  those  who  have 
learned  to  invariably  heal  a  fresh  wound  by  primary  adhesion,  as  this  is  the 
first  and  sole  test  of  the  ]30ssession  of  the  ability  justifying  such  a  grave 
iindertaking. 

Emergencies  will  necessarily  involve  varying  modifications  of  the  means, 
never  a  deviation  from  the  principle  of  asepticism. 

A  hasty  tracheotomy  for  the  removal  of  a  foreign  body,  a  herniotomy 
to  be  done  in  the  dead  of  night  amid  the  squalid  surroundings  of  a  tene- 
ment, or  the  first  care  of  a  compound  fracture  or  a  gunshot-wound,  will 
present  special  and  varying  difficulties,  to  be  overcome  only  by  good  train- 
ing, circumspection,  and  versatility.  They  can  be  overcome,  as  many 
examples  in  the  experience  of  every  successful  surgeon  testify. 

In  addition  to  the  case  of  compound  fracture  of  the  elbow-joint  quoted  on 
page  14,  another  instructive  case  may  be  told  from  the  author's  experience. 

Case. — Herman  John,  laborer,  aged  sixty-one.  Right,  irreducible,  strangulated 
femoral  hernia.  Rupture  of  long  standing,  strangulated  since  the  evening  of  April  1, 
1882.  Symptoms  of  great  acuity  necessitated  prompt  action.  Dr.  H.  Wettengel,  the 
family  attendant,  administered  the  antestlietic  in  the  middle  of  the  afternoon  of  the 
following  day,  while  author  was  making  the  necessary  preparations  for  the  presuma- 
bly inevitable  operation.  The  place  was  a  narrow,  dark,  rear  room  of  a  rear  bouse  of 
a  squalid  tenement,  and  a  lamp  had  to  be  procured.  The  divested  patient'^  pubic  and 
inguinal  region  was  shaved,  while  anassthesia  progressed.  A  flat  bake-pan  was  covered 
with  one  of  the  few  clean  towels  to  be  had ;  on  this  were  spread  the  instruments,  and 
over  thetn  was  poured  a  quantity  of  a  five-per-cent  carbohc  lotion.  No  sponges  were 
on  hand,  as  the  summons  had  been  very  hasty,  and  no  time  was  aiforded  for  prepara- 
tions. Therefore,  a  part  of  a  clean  bod-sheet  was  torn  into  a  number  of  small  pads, 
which  were  well  soaked  in  the  same  lotion  to  serve  as  sponges.  A  remnant  of  the 
lotion  was  saved  in  a  pitcher  for  purposes  of  irrigation.  After  an  unsuccessful  attempt 
at  reposition,  the  inguinal  region  and  the  surgeon's  hands  were  once  more  well  soaped 
and  washed  off  with  the  carbolic  lotion.  The  epigastric  artery  had  to  be  tied,  and  ex- 
ternal herniotomy  was  performed.  A  small  knuckle  of  gut  slipped  back  easily  into  the 
abdominal  cavity,  but  evidently  did  not  represent  all  the  contents  of  the  sac,  within 
which  an  additional  soft  body  could  be  felt  that  resisted  every  gentle  effort  at  reposi- 
tion. The  sac  being  opened,  a  slender  portion  of  omentum  was  found  to  be  adherent 
to  it.  This,  being  dissected  away,  was  replaced  into  the  abdominal  cavity.  The  outer 
wound  was  well  irrigated,  and  united  by  a  number  of  catgut  sutures.  A  few  strands 
of  catgut  were  inserted  into  the  lower  angle  of  the  wound  for  drainage.  In  the  ab- 
sence of  other  dressings,  a  clean  sheet  was  used  for  the  manufacture  of  a  number  of 
compresses  and  roller-bandages.  These,  being  well  soaked  in  carbolic  lotion,  were 
applied  to  the  wound  in  the  shape  of  a  spica  bandage.  Vomiting  ceased.  Oozing 
being  very  scanty,  the  dressings  soon  became  dry,  and,  the  patient's  condition  being 
excellent  in  every  respect,  they  were  not  disturbed  until  a  fortnijiht  after  the  opera- 
tion, when  the  wound  was  found  healed  throughout  by  the  first  intention. 


ASEPTIC   WOUNDS— ASEPTIC    TREATMENT. 


25 


Yet  it  must  be  siiid  that  such  conditions  render  operating  very  risky, 
and  in  every  way  uncomfortable.  If  unavoidable,  the  additional  risk  must 
be  shouldered  by  the  patient  as  well  as  the  surgeon. 

Operating  Bag  and  Kit.— 
Timely  preparation  made  in 
the  shape  of  procuring  a  well- 
arranged  hand-bag,  contain- 
ing the  most  necessary  arti- 
cles for  operating  in  an  emer- 
gency, will  well  repay  the 
small  expense  and  trouble. 

A  leather  hand-bag,  about 
sixteen  inches  long,  will  be 
sufficiently  large. 

Have  a  sufficiently  long, 
rather  stout  strap  sewed  to 
one  side  of  the  interior  of  the 
bag,  so  as  to  provide  loops  for  five  or  six  bottles,  which  will  be  held  safely 
in  the  upright  position.  The  first  loop  will  be  occupied  by  a  half-pound 
tin  can  of  etKer ;  the  second  is  allotted  to  a  two-ounce  bottle  of  corrosive- 
sublimate  solution  (ten  per  cent  alcoholic)  ;  the  third  to  a  four-ounce  bottle 
of  pure  carbolic  acid  ;  the  fourth  to  a  wide-mouthed  bottle  containing  cat- 
gut and  silk  of  different  sizes  on  spools  ;  the  fifth  to  a  wide-mouthed  bot- 


FiG.  5. — Author's  operating   bug,  witli  tin   jDans   and 
rubber  cloths  strapped  to  it. 


X 


Fig.   6. — Interior  of  operating  bag. 

tie  filled  with  drainage-tubes  of  different  sizes  in  carbolic  lotion  ;  the  sixth 
to  a  wide-mouthed  fruit-jar  with  tight  cap,  containing  two  or  three  dozen 
sponges  in  carbolic  lotion.     A  stout  pair  of  scissors  for  cutting  the  dress- 


26 


RULES  OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 


ings,  a  dressing-forceps  for  the  an^esthetizer,  and  a  razor  can  be  conveniently 
stuck  in  behind  the  bottles.  On  the  other  side  of  tlie  bag  two  more  spaces 
are  reserved  for  a  dusting-box  filled  with  iodoform-powder  and  a  wide- 
mouthed  vial  for  an  assortment  of  surgeon's  needles.  The  bottles  contain- 
ing pure  carbolic-acid  and  corrosive-sublimate  solution  should  be  inclosed 


Fig.  7. — German  instnunent-pouch. 


Fig. 


-Interior  ot'  German  instrument-pouch. 


in  boxwood  or  tin  cases  for  safety.  A  side-flap  will  hold  nail-brush,  safety- 
pins,  and  one  complete  dressing  rolled  up  in  a  clean  towel.  The  body  of 
the  bag  is  reserved  for  the  instruments,  which  are  rolled  up  in  another  clean 
towel,  and  for  three  or  four  small  tin  basins,  together  with  a  fountain  syringe 
and  ether  cone,  each  kept  in  a  separate  rubber  sponge-bag. 

To  the  bottom  of  the  hand-bag  is  strapped  on  the  outside  a  nest  of  four 
oblong  tin  pans  of  fitting  size. 

Such  a  bag  contains  all  the  necessaries  for  an  emergency,  and  has  been 
used  by  the  author  seven  years  with  much  satisfaction. 

Note. — Surr/ical  pocket-cases,  as  generally  sold  by  surgical  cutlers,  are  mostly  incomplete 
and  unsatisfactory.  Their  main  objection  is  the  small  size  and  frailty  of  the  instruments  con- 
tained in  them.  The  instrument-pouch  depicted  in  Figs.  7  and  8  is  very  complete,  and  is  wcrn 
strapped  to  the  waist  underneath  the  coat.  It  contains,  besides  the  instruments  held  by  a  com- 
plete pockot-case,  a  sharp  spoon,  a  key-hole  saw,  a  flat  oblong  iodoform  dnsling-box  of  hard 
rubber,  and  a  set  of  diverse  detachable  knife-blades,  that  can  be  Htted  to  smooth  hard-rubber 
handles,  all  very  easy  to  clean.  In  an  emergency,  the  hip-pouch  will  be  found  large  enough  for 
the  reception  of  one  complete  dressing  to  a  moderate-sized  wound. 


SOILED   WOUNDS— ANTISEPTIC  TREATMENT.  27 


CHAPTER    in. 

SOILED  WOUNDS— ANTISEPTIC  TREATMENT.— DIFFERENCE  BETWEEN 
ASEPTIC  AND  ANTISEPTIC  METHODS.— ILLUSTRATION  OF  ANTI- 
SEPTIC METHOD. 

In  the  prececlino-  chapter  the  treatment  of  freshly  made,  clean,  or  un- 
contaminated  wounds  was  discussed  ;  its  subject  was  the  aseptic  form  of 
treatment — that  is,  the  manner  in  which  a  fresh  or  clean  wound  has  to  be 
managed  in  order  to  prevent  its  septic  infection. 

The  aseptic  discipline  is  a  purely  preventive  one. 

Antiseptic  treatment,  on  the  other  hand,  refers  to  such  wounds  as  have 
become  the  seat  of  infection,  causing  inflammation,  suppuration,  or  the 
higher  forms  of  sepsis — phlegmon  and  gangrene.  The  object  of  the  anti- 
septic treatment  is  the  limiting  and  elimination  of  establislied  septic  pro- 
cesses by  drainage  and  disinfection.  It  is  also  preventive,  but  in  a  narrower 
sense  than  the  aseptic  method.  There  all  mischief  is  prevented  from  the 
outset ;  here  further  extension  of  present  mischief  is  sought  to  be  checked. 
The  aseptic  method  will  generally  preserve  all  the  parts  involved  ;  the  anti- 
septic method  can  not  restore  the  integrity  of  parts  destroyed  by  ulceration, 
suppuration,  or  gangrene. 

Illustration  of  Antiseptic  Metliod, — For  the  sake  of  illustration,  let  us 
go  back  now  to  our  former  example  of  breast-amputation. 

Some  gross  fault  having  been  committed,  such  as,  for  instance,  the  use 
of  unclean  instruments,  or  a  sponge  that,  having  fallen  to  the  floor,  was 
picked  up  by  the  nurse  and  was  handed  for  use  in  the  wound.  The  mild 
course  of  the  case  is  compromised,  and  trouble  will  follow. 

In  such  cases  the  patient's  general  condition  is  deeply  disturbed,  more 
or  less  high  fever  is  present,  with  headache,  sickness,  general  dejection,  and 
drawing  pains  in  the  limbs.  The  tongue  is  foul,  much  thirst  and  loss  of 
appetite  are  complained  of.  The  wound  is  painful  and  throbbing,  and  the 
patient  dreads  any  movement  lest  the  sore  parts  be  hurt. 

Under  these  circumstances  an  immediate  examination  of  the  wound  is 
imperative.  The  preparation  mentioned  in  the  preceding  chapter  being 
made,  the  wound  is  exposed.  Its  edges  and  the  vicinity  will  be  found  angry- 
looking,  swollen,  hot,  and  tender. 

The  stitches  should  be  all  removed.  The  point  of  the  grooved  director 
should  be  inserted  between  the  edges  of  the  wound,  which  are  gradually 
separated  till  the  index-finger  can  be  insinuated.  Exerting  gentle  pressure, 
the  wound  is  thus  opened  throughout  its  entire  extent.  One  or  more  small 
foci  containing  pus  will  be  laid  open  and  discharged.  The  wound  should 
be  carefully  irrigated  with  warm  mercuric  lotion  till  the  slight  hsemorrhage 
ceases,  and  lightly  filled  with  sublimated  gauze.  After  this  the  outer  dress- 
ings, with  the  addition  of  an  externally  placed  piece  of  rubber  tissue  to  pre- 


28  RULES   OF   ASEPTIC   AND  ANTISEPTIC  SURGERY. 

vent  evaporation,  should  be  renewed,  and  the  timely  interference  will  be 
soon  rewarded  by  a  decided  improvement  in  the  patient's  condition.  In 
these  cases  the  dressings  must  be  changed  as  often  as  they  become  soiled 
through.  If  the  fever  should  continue,  renewed  search  must  be  instituted 
for  overlooked  points  of  retention. 

In  some  cases  examination  of  the  wound  will  reveal  only  partial  or  quite 
circumscribed  inflammation.  In  locating  the  exact  point  of  retention,  the 
sensations  of  an  intelligent  patient  will  greatly  aid  the  surgeon.  If  the 
retention  be  near  the  edges  of  the  wound,  the  grooved  director  will  easily 
separate  them  and  find  its  way  into  the  focus.  A  dressing-forceps  should 
be  then  insinuated  along  the  director,  and  withdrawn  with  its  branches 
partly  opened.  Pus  escaping,  a  slender  drainage-tube  should  be  inserted 
into  the  track. 

If  the  point  of  retention  be  remote  from  the  edges  of  the  wound, 
and  its  locality  well  marked  by  redness  and  pain,  an  incision  will  best 
answer  the  purpose,  and  often  may  prevent  suppuration  of  the  rest  of 
the  wound. 

Let  us  assume  that  for  one  reason  or  another  nothing  efficient  was  done 
to  relieve  the  patient  on  the  second  or  third  day  after  tlie  operation.  Finally, 
the  increasing  severity  of  the  symptoms  Vv^ill  compel  some  action,  and,  the 
wound  being  laid  bare,  the  following  state  will  be  generally  met  with  :  The 
wound  will  be  more  or  less  gaping,  ichor  or  pus  escaping  everywhere  ;  the 
skin  Avill  appear  flushed,  swollen,  and  painful ;  the  edges  of  the  wound  will  be 
marked  by  a  grayish-yellow,  closely  adherent  coating,  that  extends  through 
its  whole  interior.  This  coating  represents  molecular,  often  deep-going 
necrosis  of  the  wound  surface.  Independent  abscesses  will  often  be  found 
established  along  the  connective-tissue  planes  contiguous  with  the  wound, 
and  should  be  forthwith  incised  and  drained.  The  wound  should  be  well 
irrigated  and  loosely  filled  with  sublimated  gauze.  Over  this  should  be 
applied  a  moist  dressing  of  ample  proportions,  covered  with  an  overlapping 
piece  of  rubber  tissue  to  prevent  evaporation  and  inspissation.  The  secre- 
tions will  thus  be  readily  and  continuously  drained  away  and  disinfected, 
and  the  warm  moisture  of  the  dressings  will  at  the  same  time  exert  a  very 
soothing  influence  upon  tlie  inflamed  parts.  Frequent,  at  least  daily,  change 
of  dressings  is  proper,  accompanied  by  copious  irrigation.  Detached  shreds 
of  necrosed  tissue  should  be  removed  witii  thumb-forceps  and  scissors.  If 
new  abscesses  foi'm,  they  must  be  found  and  opened  promptly.  The  fever 
will  soon  abate,  and  the  wound  will  gradually  assume  a  clean  granulating 
appearance.  As  the  amount  of  secretion  diminishes,  the  dressings  should 
be  changed  less  fref(uently. 

Essentially,  the  so-called  "  idiopathic  "  pldegmon,  or  spontaneous  sup- 
puration (abscess)  is  a  form  of  local  septic  infection  which  can  be  traced 
back  to  an  infection  extending  from  a  lesion  of  the  skin  or  the  mucous 
membranes. 

Even  the  suppurative  or  infectious  form  of  osteomyelitis  must  be  classed 
under  this  heading. 


THE  TREATMENT  OF  ACCIDENTAL   WOUNDS.  29 

« 
But,  on  account  of  the  great  practical  importance  of  the  subject,  requir- 
ing special  consideration  of  several  anatomical  regions  involving  imporhuit 
modifications  of  the  antiseptic  procedure,  it  is  deemed  expedient  to  treat 
of  this  theme  in  a  special  chapter. 


CHAPTER   IV. 


SPECIAL    RULES  REGARDING    THE   TREATMENT   OF  ACCIDENTAL 

WOUNDS. 

I.     TEMPORARY    MEASURES. 

Taking  charge  of  a  fresh  case  of  accidental  wounding,  the  surgeon 
should  bear  in  mind  that,  on  the  one  hand,  by  the  avoidance  of  suppura- 
tion, a  complete  or  almost  complete  restitution  of  normal  conditions  can  be 
accomplished  in  a  great  majority  of  cases  ;  on  the  other  hand,  suppuration 
will  enormously  increase  the  gravity  of  a  given  injury.  A  compound  fract- 
ure of  the  leg,  or  an  incised  wound  of  the  wrist,  with  opening  of  joints  and 
severing  of  arteries,  veins,  and  tendons,  may  serve  as  examples. 

In  approaching  a  fresh  case  of  bloody  injury,  we  should  always  consider 
the  possibility  that  the  wound  may  be  surgically  clean,  or  may  still  be  asep- 
tic, and  that  our  first  ministrations  should  not  carry  septic  contamination 
into  the  wound,  and  thus  harm  the  patient  instead  of  aiding  him.  As  a 
matter  of  fact,  a  large  proportion  of  incised  and  lacerated  wounds,  of  com- 
pound fractures  by  blunt  force  or  gunshot,  are  aseptic.  They  need  no  dis- 
infection. The  surgeon's  first  object  should  be  in  these  cases  not  to  spoil 
matters  by  hasty  action  and  ill-considered  zeal.  With  the  comparatively 
rare  exception  of  injuries  to  large  vessels  accompanied  by  dangerous  haem- 
orrhage, where  immediate  action  is  imperative,  conditions  should  be  created 
by  the  surgeon,  under  which  safe — that  is,  aseptic — approach  to  the  wound 
is  made  possible.  Temporary  protection  of  the  wound  in  the  shape  of  a 
simple  dressing  is  meant  thereby.  lodoform-powder  dusted  profusely  over 
the  wound  and  its  vicinity,  a  compress  made  of  a  clean  towel  dipped  in  hot 
water  or  carbolic  lotion,  also  well  dusted  with  iodoform  and  tied  on  to  the 
wound,  will  be  sufficient.  The  addition  of  a  temporary  splint  in  cases  of 
compound  or  gunshot  fracture  will  make  transportation  to  the  patient's 
home  or  to  a  hospital  possible,  and  will  thus  afford  time  for  the  absolutely 
necessary  preparations.  Extensive  or  even  superficial  examination  of  an 
accidental  wound  by  probing  or  digital  exploration  in  the  street,  on  a  train, 
or  in  a  railroad-station  or  drug-shop,  is  strongly  to  be  condemned,  as  it 
almost  necessarily  exposes  the  wound  to  unavoidable  infection.  Meddle- 
some and  untimely  surgery  of  this  kind  smacks  of  ostentation,  is  unneces- 
sary, and  in  many  cases  positively  more  dangerous  than  the  injury  itself. 


30 


RULES   OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Berguianii's  exjierienco  during  the  Eusso-Turkisli  war  has  shown  that  most 
gunshot  wounds  ai*e  aseptic,  and  that,  witli  the  exception  of  those  cases 
where  shreds  of  soiled  clothing  or  gun-wads  were  carried  along  by  the  pro- 
jectile into  the  bottom  of  the  wound,  healing  without  suppuration  can  be 
confidently  exjiected  if  the  wound  is  not  infected  by  meddlesome  and  un- 
cleanly surgery.  These  exj)eriences  refer  principally  to  gunshot  fractures 
of  the  knee-joint. 

As  a  matter  of  fact,  it  may  be  safely  assumed  that  an  examination  by 
probing  or  digital  exploration,  performed  on  the  filthy  floor  of  a  public 
place  or  on  the  street  pavement,  even  by  the  most  experienced  surgeon,  can 
not  be,  and  is  not  cleanly  or  aseptic.  It  is  extremely  dangerous,  unnecessary, 
hence  culpable.  Even  in  most  cases  of  profuse  arterial  haemorrhage,  mesial 
constriction  with  an  extemporized  tourniquet,  as,  for  instance,  the  "  Span- 
ish windlass,"  or  digital  compression  of  the  afferent  arterial  trunk,  can  be 

successfully  employed,  while  the  patient 
is  transferred  into  a  suitable  locality, 
where  permanent  relief  can  be  safely  af- 
forded by  deligation. 

The  collected  and  businesslike  manner 
of  the  surgeon  will  at  once  allay  confu- 
sion, prevent  hasty  and  injurious  interfer- 
ence,  will   infuse    the   patient  and  those 
present   with   hope   and   confidence,  and 
will  facilitate  well- 
considered  and  ra- 
tional action. 

As  a  rule,  the 
fate  of  a  fresh 
wound  is  deter- 
mined by  the  views 
and  training  of  the 
physician  who  first 
attends  to  it.  If 
the  patient  be   so 

fortunate  as  to  fall  in  with  a  man  fully  imbued  with  the  spirit,  and  familiar 
with  the  practice  of  aseptic  surgery,  he  is  truly  to  be  congratulated,  because 
his  chances  of  avoiding  suppuration  are  excellent.  If  his  first  attendant  be 
one  of  the  still  numerous  band,  to  whom  wound  infection  by  dust  or  filth 
adherent  to  hands  or  a  probe  be  a  myth,  woe  unto  him  !  Without  previous 
cleansing,  immediate  probing  of  the  gunshot  wound  of  a  vertebra,  for 
instance,  accompanied  by  digital  exploration,  will  be  performed  on  the 
patient  extended  on  a  mattress  laid  on  the  dirty  floor  of  a  railroad  station. 

Of  course,  the  bullet  will  not  be  found,  and  nothing  beyond  the  infec- 
tion of  the  wound  will  be  accomplished.  A  dressing  will  be  applied  any- 
way, and  the  patient  will  be  taken  liome.  Suppuration,  that  otherwise 
might  have  been  avoided,  will  surely  set  in,  and  the  patient  is  doomed.     No 


Fig.  9. — Extemporized  tourniquet — "  Spanisli  windlass. 


THE  TREATMENT   OF   ACCIDENTAL  WOUNDS.  31 

amount  of  consulting  can  devise  a  way,  for  no  surgical  skill  can  establish 
efficient  drainage  of  the  inaccessible  parts  of  the  wound.  The  chances  for 
recovery  were  thrown  away  here  from  the  outset. 

On  taking  charge  of  a  fresh  wound,  the  fearful  and  often  irremediable 
consequences  of  a  Inrst  false  step  should  be  always  present  to  the  mind  of 
the  surgeon,  and  his  attention  should  be  directed  chiefly  to  the  avoidance  of 
septic  infection.  A  temporary  aseptic  dressing  having  been  applied,  the 
general  condition  and  comfort  of  the  patient  should  be  looked  to  by  the 
administration  of  stimulants  or  sedatives.  After  transfer  home  or  to  a 
hospital,  the  necessary  measures  for  permanent  relief  should  be  carried  out 
as  soon  as  the  patient's  general  condition  will  permit. 

II.    DEFINITIVE    RELIEF. 

Preparations,  comprehensive  and  thorough,  as  required  for  an  aseptic 
operation,  should  now  be  made  in  the  manner  described  in  Chapter  IL- 

The  patient  is  well  stimulated  if  necessary,  is  anaesthetized  if  the  case 
require  it,  and,  his  clothing  being  removed  by  cutting  or  in  some  other 
proper  manner,  he  is  placed  on  the  operating  table. 

After  this  should  come  a  careful  cleansing  and  sterilization  of  the  sur- 
geon's and  his  assistant's  hands  by  scrubbing  with  soap  and  brush  and 
immersion  in  a  germicide  lotion,  followed  by  a  likewise  thorough  cleansing 
of  the  integument  in  the  vicinity  of  the  wound.  Plenty  of  soap-lather, 
with  the  use  of  a  razor,  scrubbing  with  soaj)  and  brush,  rubbing  and  wash- 
ing off  with  a  solution  of  corrosive  sublimate,  will  soon  accomplish  this. 

1.  Contaminated  Wounds. — The  character  of  further  procedures  will  have 
to  be  decided  by  the  answer  to  the  question  :  Is  the  ivound  clean  or  is  it  con- 
taminated'^ Grross  evidence  of  contamination,  such  as,  for  instance,  street- 
dirt  imbedded  in  the  wound  or  the  clots,  or  the  knowledge  that  the  wound- 
ing was  done  with  a  filthy  instrument,  as,  for  instance,  a  foul  and  fetid 
butcher's  cleaver,  will  answer  the  question  in  the  affirmative.  In  these 
cases  the  leading  object  should  be  thorough  cleansing  and  disinfection 
of  the  wound,  followed  by  very  comj)rehensive  measures  at  drainage.  If 
the  external  w^ound  be  small,  it  has  to  be  well  enlarged,  so  as  to  aSoi'd  a 
good  insight.  Every  nook  and  recess  of  the  wound  should  be  systematically 
gone  through,  cleansed  of  clots  and  dirt,  thoroughly  irrigated,  and  well 
drained.  Great  care  must  be  taken  not  to  overlook  recesses,  as  one  particle 
of  filth  left  behind  unawares,  may  cause  very  grave  trouble. 

Drainage  of  the  more  remote  recesses  should  be  made  as  direct  as  possi- 
ble ;  that  is,  a  rubber  tube  carried  to  the  surface  from  a  distant  corner  of 
the  wound  through  a  properly  placed  counter-incision,  will  be  more  direct, 
therefore  better,  than  a  long  tube  bent  or  twisted  and  brought  out  through 
a  distant  opening. 

Hsemorrhage  must  also  be,  of  course,  well  stanched  by  ligature  or 
otherwise. 

Divided  tendons,  nerves,  muscles,  or  fractured  bones  are  next  united  by 


32  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

suture,  and,  if  the  edges  of  the  wound  be  viable,  they  are  also  approximated 
by  sutures.  Where  extensive  loss  of  substance  precludes  uniting  of  the 
edges,  or  where  uncontrollable  oozing  prevails,  the  wound  should  be  packed. 
This  is  best  done  by  first  lining  the  entire  wound  with  one  layer  of  iodo- 
formized  gauze,  within  which  is  packed  a  suitable  number  of  loose  balls  of 
sublimated  gauze.  After  a  final  irrigation  and  clearing  of  the  drainage- 
tubes,  the  wound  and  its  vicinity  are  enveloped  in  a  moist  dressing  that 
should  be  protected  from  evaporation  by  a  large  piece  of  rubber  tissue  or 
Mackintosh.     In  case  of  fracture,  the  limb  is  sujjported  by  a  splint. 

On  account  of  their  frequency,  and  their  gravity  in  case  of  suppuration, 
scalp-Avounds  and  their  treatment  may  receive  special  mention. 

Scalp-wounds  have  been  held  undeservedly  in  bad  repute  on  account  of 
their  alleged  tendency  to  suppurate.  They  heal  as  kindly  as,  and  in  fact, 
on  account  of  their  great  vascular  supply,  heal  better  than,  many  other 
wounds,  provided  that  they  be  first  carefully  cleansed,  well  drained  before 
suturing,  and  sufficiently  protected  by  a  suitable  dressing  from  subsequent 
contamination. 

In  case  of  a  greater  denudation  of  the  cranium,  the  loose  scalp  should 
be  raised  (after  shaving  and  thorough  cleansing  of  the  skin),  blood-clots 
should  be  turned  out,  and  the  wound  well  irrigated  and  rubbed  out  with 
corrosive-sublimate  lotion.  A  bistoury  is  inserted  into  the  deepest  part  of 
the  recess  formed  by  the  flap,  and  thrust  out  through  it.  Into  this  opening 
a  short  piece  of  slender  tubing  is  placed,  after  which  the  edges  of  the 
wound  are  brought  together  by  an  exact  line  of  sutures.  A  dry  dressing  will 
be  proper  in  these  cases. 

If  the  steps  described  above  are  adequately  taken,  as  a  rule  no  septic 
fever  and  no  destructive  suppuration  will  follow  an  accidental  injury ; 
though  aseptic  fever,  due  to  absorption  of  non-decomposed  secretions,  may 
often  enough  be  observed. 

Tissues  or  bone  whose  vitality  was  compromised  by  the  crushing  force 
causing  the  injury  will  be  gradually  detached.  This  will  be  accompanied 
by  a  rather  scanty  secretion  of  thinnish  sero-pus,  and  very  little  fever,  if 
any. 

Case. — P.  S.,  aged  thirty -six,  was,  January  26,  1886,  run  over  by  a  heavily  laden 
truck,  and  was  at  once  brought  to  the  German  Hospital,  where  he  was  anaesthetized 
about  two  hours  after  tlie  accident.  Under  strict  precautions  the  wound  was  examined. 
A  laceration  of  the  integument  in  front  of  and  corresponding  to  the  middle  of  the  left 
leg.  four  inches  long,  was  found.  Compound  comminuted  fracture  of  the  tibia  and  fibula. 
The  tibia  was  broken  into  four,  the  fibula  into  at  least  three  fragments.  Severe 
haemorrhage  from  the  torn  tibialis  antica  artery  had  caused  an  enormous  infiltration  of 
the  leg,  which  had  attained  double  the  size  of  its  fellow,  and  was  quite  cold. 
Esmarch's  bandage  was  applied,  the  external  wound  was  enlarged  to  about  eight  inches, 
the  massive  clots,  some  containing  particles  of  street  dirt,  were  turned  out  of  the 
muscular  interstices,  and  from  between  the  fragments  one  perfectly  detached  piece  of 
the  tibia  was  extracted.  From  the  middle  of  the  main  cavity  into  which  the  frag- 
ments protruded,  a  counter-incision  was  made  backward  through  the  calf  of  the  leg, 
into  which  a  large-sized  drainage-tube  was  placed.     Three  more  counter-incisions,  cor- 


THE   TREATMENT  OF  ACCIDENTAL  WOUNDS.  33 

responding  to  as  many  recesses,  were  made.  Tlie  torn  artery  could  not  be  found.  A 
large  moist  dressing  was  applied,  and  tlie  limb  fixed  between  two  well -padded  lateral 
board  splints,  held  together  by  a  pure  gam  bandage.  Moderate  oozing  soiled  the 
dressings  somewhat  during  the  following  night,  wherefore  the  elastic  bandage  was 
removed  in  the  morning,  and  the  soiled  parts  of  the  underlying  dressing  were  well 
dusted  with  iodoform.  Another  envelope  of  gauze  was  laid  on  top  of  the  old  dressings 
and  the  splints  were  replaced  and  fastened  with  muslin  bandages.  Jan.  Slat. — The 
patient's  temperature  had  not  risen  above  100°  Fahr.,  he  complained  of  very  little  pain, 
no  htemorrhage  had  followed,  the  circulation  of  the  limb  was  good,  hence  the  dressings 
were  not  disturbed  until  this  date.  The  wound  was  found  to  be  in  good  condition  ; 
some  blood-clots  were  still  adherent  to  the  drainage-tubes.  Wound  was  re-dressed  and 
limb  put  up  in  a  solid  plaster- of-Paris  splint.  In  the  beginning  the  dressings  were 
changed  about  weekly;  from  February  15th,  every  fortnight.  March  3d. — After  the 
exuberant  granulations  surrounding  it  had  been  scraped  away,  the  entire  belly  of  the 
tibialis  anticus  muscle  was  found  to  be  of  a  grayish-yellow  color  and  necrosed.  It  was 
not  putrid,  although  a  good  deal  of  secretion  was  present.  The  wound  was  enlarged 
and  the  necrosed  muscle  was  removed.  Thereafter  the  secretion  diminished  materially, 
although  five  sequestra  were  consecutively  removed.  Consolidation  was  rather  slow, 
but  finally  complete,  so  that  tlje  patient  was  able  to  walk  without  support  in  Octo- 
ber of  the  same  year.  Shortening  about  one  inch.  If  left  to  themselves,  deep-seated 
and  extensive  contaminated  wounds,  presenting  a  small  external  orifice,  are,  for  obvi- 
ous reasons,  most  dangerous.  Free  exposure,  thorough-going  cleansing  and  disinfection, 
together  with  good  drainage,  are  then  imperative. 

2.  Aseptic  Wounds. — The  nature  of  many  wounds  and  their  causation 
are  such  as  to  preclude  the  probability  of  contamination.  Most  gunshot 
wounds  and  many  compound  fractures  belong  to  this  class.  In  these  cases 
interference  should  be  very  discreet.  It  should  consist  of  thorough  cleansing 
of  the  integument,  ordinarily  an  aseptic  dry  drefssing,  or,  in  case  of  doubt, 
of  superficial  drainage  and  a  moist  dressing,  together  with  reduction  and 
support  and  retention  by  splint  where  a  fracture  requires  it. 

Case. — John  D.,  aged  thirty-two,  December  4,  1885,  sustained  a  compound  com- 
minuted fracture  of  the  upper  half  of  the  tibia  by  a  horse-kick.  Dr.  W.  T.  Kudlich,  of 
Hoboken,  saw  him  immediately  after  the  accident,  cut  off  the  clothing,  disinfected  the 
vicinity  of  the  small  wound,  and  dressed  it  amply  with  iodoform  gauze.  A  temporary 
splint  was  also  applied,  and  prohing  or  examination  teas  thoughtfully  refrained  from. 
The  patient  was  brought  to  his  home,  where,  the  next  day,  he  was  anaesthetized.  The 
temporary  splint  and  dressings  were  removed,  the  vicinity  of  the  wound  was  carefully 
cleansed  and  disinfected,  and,  with  the  observance  of  all  necessary  cautelce.,  a  thorough 
examination  of  the  injury  was  instituted.  A  compound  comminuted  fracture  was  easily 
made  out,  and  three  loose  fragments  of  bone  were  removed.  The  laceration  of  the 
soft  parts  and  ecchymosis  were  found  very  moderate,  and  confined  to  the  tissues  an- 
terior to  the  tibia.  A  couple  of  short  drainage-tubes  were  inserted  into  two  recesses, 
and,  the  wound  being  well  irrigated,  was  enveloped  in  a  moist  dressing.  The  limb 
was  put  up  in  a  solid  plaster-of-Paris  sphnt,  with  the  knee  bent  at  an  obtuse  angle, 
and  was  suspended  from  a  frame. 

The  temperature  remained  normal  or  almost  noi-mal  throughout. 

Dec.  18th. — Appearance  of  wound  normal.  Moderate  secretion  due  to  limited 
necrosis  of  a  loose  fragment  of  bone.  Dec.  28th. — Second  change  of  dressings.  Ex- 
uberant granulations  have  filled  up  the  defect.     Jan.  18th.— A  fenestrated  silicate-of- 


34  RULES   OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 

soda  splint  was  applied.  The  secretion  continued  to  be  scanty.  In  May  consolidation 
was  perfect,  but  a  small  sinus  remained  until  October,  when,  after  the  extraction  of 
several  small  spicula  of  bone,  definitive  healing  of  the  wound  ensued.  No  appreciable 
shortening  resulted. 

Note. — In  the  more  extensive  injuries  of  the  extremities  caused  by  crushing  force,  the 
gravity  of  the  case  hinges  more  upon  the  extent  of  the  injury  to  the  soft  parts  than  to  the  bones. 
A  compound  fracture  by  direct  force — for  instance,  the  blow  of  a  hammer  upon  the  tibia,  where 
the  crushing  and  laceration  of  the  soft  parts  are  comparatively  limited — is  by  far  not  as  dangerous 
as,  for  instance,  the  stripping  off  of  the  entire  integument  of  the  lower  extremity,  or  the  crush- 
ing and  pulpification  of  the  large  muscles,  vessels,  and  nerves  situated  on  the  anterior  and 
internal  aspect  of  the  thigh,  though  these  latter  injuries  be  uncomphcated  with  fracture.  The 
shock  and  the  presence  of  extensive  thrombosis,  in  addition  to  the  fact  that,  with  the  large  quan- 
tity of  mortified  tissues,  preservation  of  the  aseptic  state  is  extremely  uncertain  and  difficult, 
class  these  injuries  among  the  most  grave  and  dangerous. 

3.  Gunshot  Wounds. — The  fact  that  most  fresh  gunshot  wounds  are  asep- 
tic has  been  jDointed  out  by  Esmarch,  and  is  now  well  established.  Reyher 
and  Bergmann's  experiences  in  the  Russo-Turkish  war  put  the  fact  beyond 
controversy. 

Wise  precaution  against  infecting  a  fresh  gunshot  wound  will  be  richly 
rewarded  by  excellent  results.  In  most  cases  cleansing  and  disinfection  of 
the  skin  in  the  vicinity  of  the  points  of  entrance  and  exit,  together  witli  a 
dry  dressing,  will  be  sufficient.  If  the  case  is  complicated  by  fracture,  a 
suitable  splint,  preferably  plaster  of  Paris  (Bergmann),  should  be  added. 

If  the  course  is  free  from  septic  fever  and  suppuration,  this  will  be  mani- 
fest within  the  first  three  or  four  days ;  in  that  case,  the  first  dressing  and 
the  splint  can  be  left  undisturbed  for  the  length  of  time  required  for  the 
accomplishment  of  bony  union. 

Plesh-wounds  will  be  healed  within  a  fortnight  or  three  weeks.  Gun- 
shot fractures  will  require  a  longer  time  for  healing  and  consolidation,  but 
are  in  no  way  different  from  ordinary  compound  fractures. 

The  projectile  will  cause  very  little  or  no  irritation  in  aseptic — that  is, 
non-suppurating — gunshot  wounds.  Generally  it  will  become  encysted. 
Search  for  the  projectile  in  the  bottom  of  the  wound  is  rarely  indicated. 
It  can  occur,  however,  that  pressure  of  a  projectile  or  its  fragment,  or  a 
sharp  spiculuni  of  bone  on  a  nerve-trunk,  may  necessitate  search  and  extrac- 
tion.    This  must  be  done  under  careful  asepsis. 

It  is  even  not  necessary  to  remove  a  projectile  lodged  under  the  skin. 
It  will  do  no  harm  if  left  there  until  the  channel  which  it  cut  by  its  passage 
through  the  tissues  is  obliterated,  when  its  removal  by  incision  can  not  lead 
to  an  infection  of  the  bullet-track. 

In  cases  of  injury  to  large  vessels  or  the  intestines,  immediate  interfer- 
ence can  not  be  delayed,  but  should  be  carried  out  under  most  rigid  anti- 
septic precautions. 

NoTK. — Recent  successes  (W.  T.  Bull)  achieved  by  immediate  laparotomy  and  suture  of  the 
wounded  intestines  justify  the  procedure. 

Where  the  nature  of  the  charge  or  the  short  distance  from  which  the 
shot  was  delivered  makes  the  entrance  of  a  gun-wad  probable,  or  where  the 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  ME:TH0D.  35 

examii)ation  of  the  supci-jaceiit  clothing  shows  a  hii-ge  defect,  reiideriiig  tlie 
probability  great  that  shreds  of  soiled  cloth  have  been  carried  to  the  bottom 
of  the  wound,  dilatation,  search,  and  extraction  may  be  indicated.  But  it 
is  better  to  wait  in  cases  of  doubt,  as  even  these  foreign  substances  may 
become  encysted  and  harmless. 

Should  suppuration  follow,  the  patient  will  not  be  worse  off  than  if  a 
fruitless  search  had  been  made  at  the  outset,  and  the  use  of  the  suppurating 
track  as  a  guide  will  materially  facilitate  the  finding  of  the  irritating  body. 

Note. — Reyher's  observations  (Volkmann's  "  Sammkmg,"  Nos.  142,  143,  18'78)  may  serve  as 
a  fair  sample  of  the  radical  change  that  has  taken  place  in  the  results  of  the  treatment  of  gun- 
shot fractures. 

Gunshot  fracture  of  the  knee-joint  was  formerly  considered  an  indication  for  immediate 
amputation.  Reyhcr  treated  eighteen  fresh  cases  aseptically — that  is,  by  simply  cleansing  and 
disinfecting  the  skin  about  the  wound,  and  occluding  the  same  by  an  antiseptic  dressing.  Where 
the  wound  was  gaping,  or  where  there  was  ground  to  suspect  the  entrance  of  dh't  or  shreds  of 
clothing  into  the  bullet-track,  dilatation,  irrigation,  and  extraction  of  the  foreign  body,  with  sub- 
sequent drainage,  was  practiced  before  the  v/ound  was  sealed  up.  Of  these  eighteen  cases,  fif- 
teen recovered,  with  movable  knee-joints — 83"3  per  cent  of  recoveries.  One  patient  died  of 
fatty  embolism  in  twenty-four  hours  after  the  injury;  another  of  hemorrhage  from  the  divided 
popliteal  artery  and  vein  on  the  fifth  day ;  and  the  third  one  of  pyaemia. 

Of  nineteen  that  came  under  his  care  several  days  after  the  reception  of  the  injury,  with 
well-established  suppuration,  eighteen  died,  and  one  recovered  with  a  stiff  joint.  In  spite  of  an 
energetic  antiseptic  treatment  by  incisions,  drainage,  and  irrigation,  a  mortality  of  85  per  cent 
was  noted. 

Of  twenty-three  that  were  not  subjected  to  any  form  of  antiseptic  treatment,  twenty-two 
died,  one  survived,  a  mortality  of  95"6  per  cent — cleai'ly  justifying  the  practice  of  the  older  sur- 
geons, who  at  once  performed  amputation  in  cases  of  gunshot  fracture  of  the  knee-joint. 

Infected  accidental  wounds  or  gunshot  injuries  that  become  the  seat  of 
suppuration  can  be  classed  under  the  heading  of  phlegmonous  processes,  and 
their  treatment  will  be  dealt  with  in  a  subsequent  chapter. 


CHAPTER   V. 
SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 

A.    General  Peinciples. 

I.     TECHNIQUE    OF    SURGICAL    DISSECTION. 

Modern  surgery  demands  that  the  invasion  of  the  uninflamed  tissues 
of  the  human  body  by  the  surgeon's  knife  should  be  surrounded  by  all  the 
safeguards  that  are  known  to  be  effective  in  preventing  suppuration.  The 
mortality  following  operations  sanctioned  by  pre-antiseptic  surgery  has  been 
remarkably  depressed  by  a  conscientious  and  intelligent  adherence  to  the 
principles  of  surgical  cleanliness.  A  large  number  of  recently  devised  use- 
ful operations  have  become  legitimate  under  the  assumption  that  suppura- 


36 


RULES   OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 


tion  can  be  excluded.  The  large  Joints,  the  tendinous  sheaths,  and  the 
peritoneal  cavity  are  now  safely  accessible  for  curative  or  even  diagnostic 
purposes. 

The  statement  that  a  real  observance  of  asepticism  offers  a  sure  guaran- 
tee against  suppuration,  be  the  performance  of  a  bloody  operation  however 
clumsy,  rough,  and  unskillful,  is  true,  but  can  not  be  pleaded  as  an  excuse 
for  the  absence  of  that  equipment  of  pathological  and  anatomical  knowledge 
and  technical  skill  which  go  toward  forming  a  good  surgeon.  Althougli 
the  general  standard  of  safety  and  success  in  surgery  has  been  considerably 
raised,  excellence  will  be  attained  by  those  only  who  unite  the  qualities  of 
a  good  diagnostician,  pathologist,  and  anatomist  with  the  tact,  energy,  and 
technical  skill  of  the  accomplished  surgeon. 

The  technique  of  surgical  dissection  is  based  upon  principles,  the  ob- 
servance of  which  enables  us  to  safely  explore  and  manipulate  any  accessible 
part  of  the  human  body. 

Aside  from  the  ever-present  desideratum  of  preA^enting  infection,  the 
avoidance  of  accidental  injury  of  important  organs  and  the  control  of  hseni- 
orrhage  first  deserve  attention. 

The  princi2)le  of  doing  every  step  of  an  operation  under  the  guidance  of 
the  eye,  is  the  most  important  discipline  of  dissection  to  be  acquired.  It 
should  never  be  sacrificed  without  the  most  stringent  necessity.  Its  non- 
observance  is  the  source  of  most  that  is  embarrassing,  appalling,  and  dis- 
astrous in  operative  work. 

Upon  this  principle  is  based  the  rule  to  always  mahe  an  ample  and  ade- 
quate incision,  which  should  be  gradually  deepened  layer  by  layer,  until 
the  part  sought  after  is  freely  exposed. 


i'lG.  10. — a,  Bellied  scalpel  for  cutaneous  iiici.sinn.     A,  Sliarji-pointcd  scalpel  for  deeper  dissection. 


For  the  cutaneous  incision  a  bellied  scalpel,  held  like  a  fiddle-bow,  is 
the  most  useful.  A  careful  and  clean  incision  will  insure  a  lineal  cicatrix. 
As  soon  as  the  skin  is  divided,  the  subcutaneous  vessels  will  become  visible. 
If  they  are  crossing  the  line  of  incision,  they  should  be  grasped  between 

two  artery  forceps,  divided 
between,  and  safely  tied 
off  with  catgut.  In  cut- 
ting through  the  fascia,  the 
grooved  director  used  to  jilay 
an  important  part  in  for- 
mer times.     Its  use  has  been 

-Mauiier  ol  lioldui;^  the  knife  tor  the  eutuiieous 

incLuioii.  supplanted  by  a  safer  mode 


SPECIAL  APPLICATION  OF  THE   ASEPTIC  METHOD. 


37 


of  preparation,  known  as  ciittimj  hcttveen  kvo  thumb-forceps.  The  author 
once  observed  that,  in  thrusting  a  grooved  director  underneath  the  fascial 
coverings  of  a  hernia,  the  hernial  sac  was  opened,  and  the  adherent  gut 
nearly  torn  through.  As  it  was,  only  its  serous  covering  was  lacerated.  In 
another  instance,  puncture  of  the  deep  jugular  vein  by  the  point  of  the 
grooved  director  happened,  and  led  to  very  annoying  hgemorrhage  from  the 
deepest  parts  of  the  wound,  which  made  exposure  and  ligature  of  the  injured 
vein  very  difficult.  It  may  be  said  that,  unless  very  thin  layers  are  taken 
up  by  the  grooved  director,  the  surgeon  never  can  tell  beforehand  what  he 
is  going  to  cut  through  while  using  it.  Veins  especially  are  easily  injured, 
as,  being  put  on  the  stretch,  they  become  empty.  Stretched,  they  lose 
their  identity  to  the  eye,  and  look  exactly  like  ordinary  connective  tissue. 


Fig.  13. 
Securing  and  tying  vessels  traversing  the  line  of  incision. 

Cutting  between  two  forceps  has  the  peculiarity  that,  a  thin  layer  of 
tissue  being  raised  before  each  cutting,  air  enters  into  and  rarefies  its  meshes, 
rendering  clearly  visible  the  vessels,  which  can  be  easily  isolated  and  secured 
before  they  are  cut.  From  this  result  two  very  great  advantages  :  First, 
tlie  patient  does  not  lose  one  drop  of  blood  from  a  vessel  secured  previous 
to  its  division  ;  and  last,  but  not  least,  the  wound  remains  dry  and  clean. 
No  time  is  lost  in  hunting  for  a  retracted  vessel  in  a  pool  of  blood,  there 
is  no  occasion  for  hasty  and  rough  sponging,  and  everybody  preserves  an 
easy  tenor  of  mind  very  essential  to  success. 

The  advice,  so  often  met  with  in  text-books,  that  the  knife  should  be 
laid  aside  where  the  tissues  are  loose,  and  that  tearing  or  scraping  with  for- 

r 


38  RULES   OF   ASEPTIC   AND  ANTISEPTIC  SURGERY. 

ceps  or  the  finger-nail  is  safer,  is,  to  say  the  least,  very  questionable.  This 
advice  is  born  of  the  fear  of  unexjoected  haemorrhage,  which,  however,  can 
be  always  avoided  by  cutting  between  two  forceps.  The  beginner,  especially, 
is  prone  to  carry  this  mode  of  blunt  preparation  to  great  lengths,  and  lacer- 
ation of  large  veins,  the  peritoneum,  or  cysts  is  the  result. 


Fig.  14. — Cutting  between  two  thumb-forceps. 

A  consideration  of  no  small  importance  is  the  fact  that  a  clean-cut  wound 
will  sometimes  heal  in  spite  of  some  local  reaction  and  fever.  This  means, 
that  the  blood-  and  lymph-vessels  of  the  parts  concerned  being  not  much 
bruised,  sufficient  nutriment  is  carried  to  the  walls  of  the  wound  to  over- 
come a  moderate  degree  of  micrococcal  infection.  Where  the  nutrition  of 
the  parts  is  seriously  interfered  with  by  tearing  and  bruising  pertinent  to 
blunt  dissection,  a  much  higher  degree  of  asepticism  is  required  to  secure 
absence  of  suppuration. 

Note. — The  old  surgical  tenet,  that  torn  and  bruised  operative  wounds  are  not  prone  to  heal 
kindly,  is  based  upon  the  fact  that  devitalized  tissues  form  an  especially  favorable  pabulum  to 
microbial  development.  The  observation  that  very  well  nourished  tissues,  as,  for  instance,  those 
of  the  face,  will  heal  readily  under  almost  all  circumstances,  and  without  the  observance  of  anti- 
septic precautions,  is  explained  by  the  fact  that  they  are  very  well  vascularized,  and  a  rich  supply 
of  oxygenated  blood  is  one  of  the  strongest  germicides.  We  often  saw  the  parts  become  red, 
swollen,  and  painful,  and  were  expecting  suppuration,  but  in  vain,  as  all  the  local  symptoms  and 
the  fever  receded,  and  good  union  followed. 

As  the  wound  is  gradually  deepened,  sharp  or  blunt  retractors  should 
be  employed  to  well  expose  to  view  its  bottom,  in  which  is  centered  the  sur- 
geon's interest.  The  skin,  muscles,  fasciae,  tendons,  or  the  periosteum  can 
be  held  back  by  sharp  retractors ;  vessels  and  nerves,  the  peritoneum,  and 
friable  glands  or  cysts  should  never  be  hooked  up  by  them,  blunt  retractors 
deserving  the  preference. 

Most  of  the  retractors  commonly  sold  by  the  instrument-dealers  are 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


39 


worthless.  A  useful  retractor  must 
have  a  good,  ample  curve,  a  propor- 
tionate and  safe  grasp,  a  smooth,  solid 
handle,  and  a  strong  shank,  so  as  to 
be  able  to  sustain  a  good  deal  of  press- 
ure without  bending:  or  breaking. 


Fig.  15.— Small 
blunt  retractors. 


Fig.  16. — Medium -sized  blunt 
retractor,     a,  Actual  size. 


Fig.  17. — Large-sized  blunt  retractor, 
b.  Actual  size. 


Fig.  19. — Large  four-pronged  sharp  retractor  (Volkmann). 


40 


EULES  OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Fig.  l'O. — Manner  of  holding  the  knife  for  deep  dissection. 


The  shapes  and  sizes  most  useful  for  general  surgical  work  are  depicted 
by  Figs.  15,  16,  17,  18,  and  19. 

The  deeper  the  knife  penetrates,  the  nearer  it  approaches  important 

organs,  the  shallower  its 
strokes  should  become. 
A  somewhat  pointed 
scalpel  should  be  used, 
and  its  strokes,  especial- 
ly where  they  sever  dense 
tissues,  should  be  made 
with  the  very  point  of  the 
instrument,  which  should 
be  held  like  a  pen,  but 
rather  steeply. 
Use  of  the  grooved  director,  or  the  scissors,  or  the  sickUsliaped  bistoury 
in  the  bottom  of  a  deep  wound  is  always  unsafe,  as  it  may  lead  to  unex- 
pected haBmorrhage  or  something  worse.  Especially  dangerous  is  the  last- 
named  instrument,  as  its  very  nature  renders  impossible  the  observance  of 
the  principle  of  not  cutting  what  we  do  not  see.  It  cuts  from  within  out- 
ward, takes  up  unseen  tissues,  and  may  become  the  cause  of  unnecessary 
trouble  and  embarrassment. 

Should  it  become  evident,  as  the  wound  deepens,  that  the  first  incision 
is  inadequate,  and  that,  in  order  to  afford  access,  its  edges  must  be  subjected 
to  severe  tension,  and  that  work  is  thereby  cramped,  an  extension  of  the 
first  incision  is  in  order.  This  should  be  done  methodically  from  without 
inward  until  the  wound  is  sufficiently  enlarged. 

Note. — The  author  once  saw  an  ovariotomist  make  abdominal  section  with  exaggerated 
minuteness,  layer  by  layer,  until  the  belly  was  opened,  tying  each  small  vessel  as  it  was  exposed. 
When  a  digital  exploration  had  made  evident  the  insufficiency  of  the  incision,  he  enlarged  it  by 
cutting  through  the  entire  thickness  of  the  abdominal  ivall  ivith  a  stout  pair  of  scissors  at  one  stroke. 
Of  course  the  incision  was  uneven,  some  layers  being  further  cut  than  others,  haemorrhage  was 
considerable,  and  finding  and  securing  of  the  retracted  vessels  not  easy. 

The  shape  of  every  operation  wound  should  be  such,  if  possible,  as  to 
afford  the  best  conditions  of  access, 

and,  later  on,  for  natural  drainage.       ^^3  -!^  f~'~—-^\ 

The  funnel  shape   (Fig.   21,   a)   is        \  / 

meant  by  this — that  is,  that  the  first  \  ,/'         /  \ 

incision  should  be  the  longest,  the  \  /  \  j 

next  one  a  little  shorter,  the  last  one  \     /  '\,  /' 

the  shortest.     Even  if  no  drainage-  '^  ^ 

tube  is  inserted  in  such  a  wound,  as 

long  as  the  closing  stitches  are  not 

too  tight  and  too  many,  the  interstices  of  the  suture  will  afford  ample 

drainage. 

Bottle-shaped  ivounds  (Fig.  21,  ^)  are  disadvantageous  in  every  way. 
They  result  from  a  too  small  cutaneous  incision,  are  uncomfortable  and 


Fio.  til. — A,  Funnel-shaped  wound, 
shaped  wound. 


B,  Bottle-' 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


41 


unsafe  duriiip^  the  operation,  and  after  closure  offer  poor  conditions  fur 
natural  drainage.  They  always  require  a  drainage-tube,  and,  even  with  a 
tube,  if  not  absolutely  aseptic,  become  a  very  hot-bed  of  suppuration,  as  the 
discharges  of  infected  recesses  may  not  find  ready  egress. 

Where  the  incision  must  be  carried  through  condensed  or  inflamed  tis- 
sues, preparation  between  two  forceps  will  be  generally  impossible.  All 
the  more  stress  should  be  laid  upon  the  amplitude  of  the  first  cut,  and  upo7i 
the  adequate  dilatation  of  the  wound  by  serviceable  and  solid  retractors.  As 
the  wound  deepens,  the  hooks  should  be  alternately  released  and  inserted 
deeper,  so  as  to  follow  up  closely  the  work  of  the  knife. 

On  account  of  their  hypersemic  state  and  density,  haemorrhage  will  be 
found  a  great  deal  more  profuse  in  inflamed  than  in  normal  tissues.  The 
presence  of  vessels  will  become  manifest  only  by  the  haemorrhage  caused  in 
cutting  them.  The  smaller  arteries  can  be  easily  controlled  by  increasing 
the  tension  exerted  by  the  retractors  on  the  edges  of  the  wound.  Larger 
vessels  must  be  tied  off.  But  the  density  and  often  the  brittleness  of  the 
tissues  prevent  grasping  of 
the  bleeding  jjoints  with 
a,rtery-f creeps,  hence  an- 
other expedient  must  be 
used. 

An  ordinary  curved,  or, 
better,  a  perfectly  round 
haemostatic  needle,  armed 
with  catgut,  is  carried  with 
a  needle-holder  through  the 
tissues  adjacent  to  the  bleed- 
ing point  in  two  or  three 
stitches,  so  as  to  surround  it 
bleedina:  orifice. 


Fig.  22. 

Haemostatic 

needle. 


Fig. 


23. — Manner  ot  ap]>l^  ing  haemostatic 
needle  (E&marcli). 


like  a  purse-string.     Being  tied,  it  closes  the 


Fig.  24. — Dieffenbach's  needle- holder. 


When  a  plexus  of  considerable  vessels,  especially  veins,  is  encountered 
in  the  bottom  of  a  wound,  or  where,  for  some  reasons,  it  is  desirable  to 
hasten  operative  work,  the  employment  of  mass  ligatures  will  be  found  an 
expedient  and  safe  way  to  rapid  progress. 

Thiersch'' s  spindle  and  forceps  is  an  invaluable  apparatus  for  applying 
mass  ligatures  to  dense  tissues  in  difficult  and  deep  situations.  A  blunt, 
probe-pointed,  curved  needle  and  a  straight  ivory  spindle,  armed  with  stout 
silk  or  catgut,  and  an  appropriate  forceps,  make  up  the  apparatus.     The 


42 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


probe-pointed  needle  is  grasped  by  tbe  beak  of  the  forceps,  and  is  cau- 
tiously insinuated  under  the  plexus  or  mass  to  be  tied  off.  Veins  and 
arteries  arc  not  apt  to  be  injured  by  the  blunt  point,  as  they  are  inclined 
to  slide  off  from  it.  As  soon  as  the  ligature  thread  is  drawn  through  under 
the  mass,  a  knot  is  made,  and,  the  spindles  serving  as  solid  handles,  it  can 
be  tightened  with  a  great  deal  of  firmness  and  security.  The  mass  can  be 
safely  divided  between  two  of  these  ligatures. 

The  treatment  of  veins  in  operative  wounds 
is  similar  to  that  applied  to  arteries.  There  are 
some  points,  however,  that  constitute  an  impor- 
tant difference,  and  deserve  special  attention.  The 
tension  exercised  by  retractors  is  very  apt  to  ob- 
literate the  normal  characteristics  of  veins.  The 
dark  blood  they  contain  is  driven  out  of  them, 
and  they  can  not  be  distinguished  from  ordinary 
connective  tissue.  Especially  in  blunt  prepara- 
tion, lacerations  of  veins  are  apt  to  occur  and 
cause  serious  difficulty.  To  find  a  bleeding  vein 
is  not  as  easy  as  to  locate  an  injured  artery,  readily 
marked  by  its  jet  of  blood.  And,  even  if  the 
bleeding  point  is  recognized,  it  is  not  always  easy 
to  stop  a  torn  vein,  as  the  laceration  may  be,  and 
in  fact  frequently  is,  an  irregular  and  extensive 
slit.  On  the  other  hand,  venous  haemorrhage  can 
often  be  effectively  checked  by  simple  pressure  or 
plugging.  If  the  finding  of  a  torn  and  retracted 
vein  should  be  difficult  and  involve  too  much 
time,  it  will  be  found  a  good  expedient  to  plug 
u})  the  place  from  which  the  hgemorrhage  issues 
with  a  strip  of  iodoformed  gauze,  held  in  place 
by  light  finger-pressure  until  coagulation  occurs. 
Formerly  the  author  used  a  bit  of  sponge  for  this 
purpose,  but  the  following  experience  has  shown  that  sponge  is  not  a  safe 
material : 

Case. — Theresa  Kops,  housewife,  aged  forty-eight.  February  10,  1883. — Ampu- 
tation of  left  breast,  with  evacuation  of  the  contents  of  the  axilla  for  scirrhus  of  the 
mammary  gland.  Wound  sutured  throughout;  drainage  by  counter-incision  through 
latissimus  dorsi.  Aseptic  dressing.  After  feverless  course,  first  change  of  dressings 
on  February  21st,  when  the  wound  was  found  united.  Drainage-tube  was  withdrawn. 
Feb.  22d. — Severe  chill,  phlegmonous  infiltration  of  axillary  region.  Feb.  23d. — Incis- 
ion through  cicatrix,  and  evacuation  of  a  large  quantity  of  pus,  followed  by  a  small 
fragment  of  sponge ;  drainage.  Uninterrupted  liealing  of  the  axillary  abscess  by 
granulation. 

In  removing  the  axillary  glands  a  small  vein  was  put  on  the  stretch, 
and,  being  ruptured,  retracted  so  far  that  it  could  not  be  found.  A  good- 
sized  sponge  was  stuffed  temporarily  into  the  recess  from  which  the  hfemor- 


FiG.  25. 


—Thiersch's  spindle 
apparatu.s. 


SPECIAL  APPLICATION  OP  THE  ASEPTIC  METHOD.  43 

rhage  issued,  and  the  operation  was  finished.  When  the  sponge  was  ex- 
tracted, it  came  away,  as  usual,  with  some  resistance,  due  to  tlie  matting 
of  the  blood-clot  into  its  meshes.  The  sponge  was  a  very  soft  and  brittle 
one,  and  its  own  cohesion  was  apparently  less  than  the  cohesion  of  its 
surface  to  the  tissues  matted  to  it.  A  small  portion  of  the  sponge  tore  off 
and  was  left  behind  in  the  wound.  It  caused  no  trouble  for  eleven  days, 
and  only  after  the  disturbance  of  its  relations  by  the  removal  of  the  drain- 
age-tube did  its  decomposition  set  in.  Since  that  time  a  strip  of  iodoformed 
gauze  was  used  for  the  mentioned  purpose  by  the  author,  which  would  not 
tear,  and  could  not  be  overlooked,  as  its  end  is  carried  out  of  the  wound 
for  a  mark. 

Close  attention  to  the  details  enumerated  above  will  secure  a  dry  and 
easily  accessible  wound.  No  sudden  and  uncontrollable  haemorrhage  will 
occur  to  create  flurry  or  alarm  ;  no  embarrassment  will  cause  undue  haste 
or  an  ill-considered  move  ;  the  patient  will  fare  well,  as,  even  with  the  seem- 
ing deliberation,  the  operation  will  be  speedily  accomplished,  and,  what  is 
the  main  thing,  no  unnecessary  loss  of  blood  will  be  sustained. 

n.     SUTURES. 

Primary  union  with  a  linear  cicatrix  is  the  ideal  of  the  healing  of  an 
aseptic  wound.  As  it  depends  to  a  great  measure  upon  an  exact  coaptation 
of  its  edges  in  such  a  manner,  that  circulation  of  the  integument  should  not 
be  interfered  with,  and  as  exact  coaptation  under  varying  circumstances 
requires  a  variation  of  the  procedure,  a  discussion  of  the  important  differ- 
ences in  the  technique  of  suturing  may  receive  some  consideration. 

Exact  coaptation  of  the  corresponding  points  of  the  edges  of  the  wound 
by  finger-pressure  or  otherwise,  lefore  and  while  passing  the  stitch,  is  the 
first  condition  of  a  true  suture.  Where  there  is  no  considerable  loss  of 
integument,  and  where  the  edges  of  the  wound  are  equally  thick  and  have 
sufiicient  body,  this  can  be  done  easily  by  compressing  the  edges  between 
the  index  and  thumb  until  they  touch  on  the  same  level.  A  good-sized 
curved  needle  is  then  passed  through  both  edges  of  the  wound,  which 
will  be  retained  in  their  correct  relation  by  simply  tying  the  catgut 
thread. 

Where  one  of  the  edges  is  thick  and  the  other  rather  thin,  coaptation 
is  more  difficult,  as  the  thinner  edge  is  apt  to  slip  back,  leaving  a  portion 
of  raw  surface  exposed.  Or  where  both  edges  of  the  wound  are  thin,  as, 
for  instance,  on  the  neck,  the  scrotum,  and  the  dorsum  of  the  hand  or 
foot,  they  have  the  tendency  to  curl  under,  raw  being  in  contact  with  epi- 
dermidal  surface.  Both  of  these  relations  will  produce  an  uneven  line  of 
suture,  and  will  frustrate  exact  primary  union.  Partial  healing  by  granula- 
tion is  then  unavoidable. 

Under  these  circumstances  the  best  result  will  be  achieved  by  the  fol- 
lowing plan  :  The  edges  of  the  wound  are  brought  together  and  pinched 
up  by  index  and  thumb  in  such  a  way  as  to  form  a  continuous  ridge,  on 


u 


RULES   OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


Fig.  26. 


the  top  of  which  sliould  ap])oar  the  line  of  incision.     A  straight  needle  is 
thrust  transTersel}'  through  the  base  of  this  ridge,  and  the  suture  is  tied 
while  the  fingers  still  retain  their  position.     The  appearance  of  the  com- 
pleted suture  is  rather  grotesque  ;  but, 
when  the  stitches  are  absorbed  or  re- 
moved, the  peculiar-looking  ridge  will 
flatten  out  spontaneously,  and  the  re- 
sult will  be  a  beautiful  fine  cicatrix. 
See  Figs.  26  and  27. 

In  tying  a  surgical  knot,  a  certain 
little  knack  will  be  found  extremely 
useful,  especially  where  good  assist- 
ance can  not  be  had.  It  consists  in 
jamming  down  the  first  or  double  cast 
into  the  angle  of  the  suture  nearest  to 
the  operator  by  a  slight  Jerk,  made  upon  the  distal  end  of  the  thread,  while 
the  mesial  one  is  held  steadily  on  the  stretch.  This  jamming  of  the  catgut 
will  be  just  sufficient  to  hold  the  edges  of  the  wound  together,  until  with 

the  second  cast  the  knot  is 
tied.  It  will  even  hold  to- 
gether edges  approximated 
with  some  degree  of  force. 

Where  there  is  much  loss 
of  integument,  as  in  many 
cases  of  breast  amputation, 
or  where  the  sutures  may 
have  to  stand  a  good  deal  of 
strain,  as,  for  instance,  the 
abdominal  stitches  after  ova- 
riotomy, aside  from  the  su- 
tures of  coaptation  above 
mentioned,  supporting  or  re- 
tentive sutures  are  necessary. 
They  have  to  embrace  a 
good  deal  more  integument 
than  the  finer  stitches,  and 
should  be  inserted  from  one 
half  to  two  inches  away  from 
the  edges  of  the  wound.  Lat- 
eral concentric  pressure  by  the  hands  of  an  assistant  will  very  much  facili- 
tate the  proper  placing  of  these  sutures. 

They  can  be  made  in  several  ways.  The  simplest  one  is  to  pass  three 
or  four  or  more  interrupted  catgut  sutures  of  wider  scope,  and  then  to  tie 
them  while  the  edges  of  the  wound  are  firmly  supported  by  an  assistant 
(Fig.  28).  The  required  number  of  finer  stitches  is  passed  afterward.  An- 
other good  way  is  the  ai)plication  of  a  mattress  suture,  illustrated  in  Fig. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


45 


29,  combined  with  a  continuous  coaptation  suture,  all  done  with  one  piece 
of  catgut. 

Where  silver  wire  or  silkworm -gut  are  available,   tlie   quill  suture  or 
Lister's  button  suture  will  give  much  satisfaction.     Both  of  these  forms  of 


Fig.  28. 


Interrupted  retentive  suture. 


Fig.  29. — Combined  mattress  suture  and  Glover's 
stitch. 


retentive  suture  will  be  very  proper  after  abdominal  operations.  For  the 
quilled  suture,  small  cylindrical  pieces  of  well-disinfected  wood  will  answer. 
Buttons  for  Lister's  retentive  suture  (Fig.  30)  are  cut  out  of  stout  sheet 
lead  with  a  pair  of  scissors.  It  is  sold  by  dental-supply  traders  under  the 
name  of  "suction  lead."     The  wire  or  gut  is  armed  with  a  perforated  shot, 


a    S' 


&     « 


Q-\a 


Fig.  30. — a.  Plate  and  shot  suture. 
b.  Interrupted  suture. 


Fig.  31. — a.  Catgut  suture  from  suppurating  stitch- 
liole.  b.  Calgut  from  sweet  stitch-hole,  nearly 
absorbed. 


which  is  clamped  to  its  end  ;  over  this  is  slipped  a  button.  The  suture  is 
passed,  and  the  needle  is  unthreaded.  Over  the  second  end  a  button  and 
shot  are  slipped,  the  stitch  is  tightened,  and  the  shot  is  clamped. 

In  uniting  more  extensive  wounds,  it  is  better  to  commence  at  the  mid- 
dle and  not  at  the  angle,  as  the  latter  way  may  result  in  uneven  distribu- 
tion and  puckering. 

After  abundant  trial  and  comparison,  the  conclusion  was  arrived  at  by 
the  author  that,  as  a  rule,  the  interrupted  suture  is  in  every  way  preferable 
to  the  continuous  one.     The  exceptions  are  mentioned  at  the  projoer  place. 

The  chief  advantage  claimed  for  the  continuous  suture — namely,  the 
saving  of  time — is  illusory.  As  regards  safety  in  holding  and  exactitude 
of  adaptation,  the  interrupted  suture  has  no  peer. 


m.     DRAINAGE. 


Small  aseptic  wounds  of  a  favorable,  that  is  funnel  shape,  do  not  re- 
cpiire  drainage  by  rubber  tubing.  As  few  stitches  should  be  taken,  how- 
ever, as  possible,  to  permit  the  escape  of  the  oozing  between  them.     Small 


46 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


wounds  of  bottle  shape  will  do  very  well  with  a  few  threads  of  catgut  placed 
in  one  angle  for  capillary  drainage.  Larger  wounds,  especially  those  with 
a  sinuous  cavity,  require  drainage  by  rubber  tubing. 

Before  using  the  tube,  a  number  of  oval  holes  should  be  clipped  out  of 
its  side. 

"  Through  drainage,^^  with  a  view  to  subsequent  irrigation,   is   best 

effected  by  placing  the  mesial  end  of  the  tube  just  within  the  cavity  to 

_  be    drained.      Drawing 

(^^'•^^^gi^^^^  ^^^^^-^S^— ^w*"''^  \^     transversely  through  the 
\^i^  '  '^^f^-^      1  ,-^.gfe:^^^'^  cavity   does   not   afford 

fiG.  32.— Perforated  rubber  drainage-tube.  ^^^^    ^^^^   Conditions   for 

thorough  irrigation,  as 
the  bulk  of  the  irrigating  stream  will  pass  directly  through  the  tube  with- 
out entering  the  cavity  at  all.  Where  two  or  more  short  pieces  of  tubing 
are  placed  just  within  the  cavity,  the  entire  mass  of  the  irrigating  stream 
is  thrown  into  the  cavity,  to  escape  through  the  ojiposite  opening  only  after 
having  washed  the  entire  extent  of  its  interior. 

Aseptic  rubber  tubes  never  cause  "irritation."  Increased  discharge  or 
irritation  of  any  kind  is  due  to  infection  introduced  into  the  wound  by 
means  of  the  tube  at  change  of  dressings.  If  the  withdrawn  tube  is 
touched  by  unclean  hands  and  is  then  reintroduced,  it  is  apt  to  cause  irrita- 
tion. But  it  is  not  the  tube  but  the  dirt  adhering  to  it  that  is  the  cause  of 
the  trouble. 

The  ]3ersistence  of  sinuses  after  certain  operations,  notably  exsections, 
was  also  attributed  to  the  use  of  drainage-tubes.  This  mistake  is  now  ex- 
plained by  the  knowledge,  that  the  sinuses  in  question  do  not  heal  on 
account  of  reinfection  by  tubercle  bacilli,  extending  along  the  tubes  with  the 
discharges  from  an  incompletely  evacuated  tubercular  focus. 

In  aseptic  wounds,  the  office  of  the  drainage-tube  is  performed  by  about 
the  end  of  twenty-four  hours  after  the  operation.  But  other  considerations, 
notably  the  unwillingness  of  disturbing  the  rest  of  the  wound  and  of  the 
patient,  make  it  inexpedient  to  reopen  the  dressings  so  soon  for  the  purpose 
of  withdrawing  the  tube.  It  is  generally  left  in  situ  until  the  first  change 
of  dressings.  If  there  is  no  purulent  discharge  visible  in  the  dressings 
removed  on  the  sixth  or  tenth  day,  the  tubes  can  be  safely  withdrawn.  If 
the  healing  was  not  entirely  faultless,  as  seen  from  the  presence  of  more  or 
less  pus  in  the  dressings,  it  will  be  safer  to  reintroduce  a  short  piece  of 
tubing  for  the  purpose  of  keeping  patent  the  external  end  of  the  tube-track 
until  the  discharges  shall  have  become  scanty  and  serous. 

When  a  wound  is  in  good  condition  and  no  pyogenic  or  tubercular 
infection  be  present,  the  surgeon  will  find  it  a  very  difficult  matter  to  keep 
a  tube  in  place  for  a  long  time,  should  he  desire  to  do  so.  The  cicatrization 
of  the  deeper  parts  of  the  drainage-hole  will  irresistibly  cxjiel  the  tube,  or 
granulations  will  invade  the  lumen  of  the  tube  through  its  lateral  fenestra, 
and  will  simply  fill  it  up  completely. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.  47 

The  tube  sliould  be  always  extracted  for  inspection  at  the  first  change 
of  dressings.  If  it  is  found  to  be  filled  up  with  a  more  or  less  solid  clot  of 
sweet  blood  or  fibrin,  the  interior  of  the  wound  can  be  assumed  to  be  in 
good  condition.  Should  the  clots  be  foul  and  semi-fluid,  the  tube  must  be 
shortened  and  replaced  after  thorough  cleansing. 

The  decalcified  bone  drainage-tubes,  devised  by  Neuber,  have  been 
abandoned  by  the  author  on  account  of  their  many  inconveniences  not  over- 
balanced by  the  advantage  of  their  absorbability. 

Neuber s  ''canalization,"  that  is,  turning  in  of  a  part  of  the  edge  of  the 
wound,  and  fastening  it  to  a  deep-lying  part  of  the  tissues  by  suture,  still 
found  a  limited  application  in  the  author's  i)ractice,  as  will  be  seen  in  the 
chapters  referring  to  it. 

It  may  be  said,  on  the  whole,  that  rubber  tubing  has  so  far  not  been 
supplanted  by  anything  better  for  purposes  of  wound  drainage. 

B.    Application"    of   Aseptic    Method   to   Diverse   Organs   and 

Eegions. 

i.  ligatures  of  arteries  in  their  continuity. 

"With  due  observance  of  the  rules  of  surgical  dissection  and  of  the  land- 
marks pointed  out  by  anatomy,  the  exposure  and  deligation  of  the  larger 
arteries  will  present  no  serious  difficulty. 

The  treatment  of  the  vascular  sheath  deserves  some  special  remark. 

Free  incision  of  the  sheath  will  be  found  to  facilitate  verj  much  the 
isolation  of  the  vessel.  No  fear  need  be  entertained  of  causing  thereby 
necrosis  or  suppuration  in  an  aseptic  wound. 


Fig.  33. — Incising  the  vascular  sheath  (Esmarch). 


The  sheath  should  be  grasped  and  raised  with  a  pair  of  mouse-tooth 
forceps,  and  the  cone  thus  formed  should  be  incised  with  the  knife  held 
horizontally.  The  incision  can  be  extended  to  half  an  inch  in  length.  See 
Fig.  33. 

Isolation  of  the  vessel  is  best  accomplished  by  gently  insinuating  into 
the  slit  the  point  of  a  bent  silver  probe,  while  the  edge  of  the  cut  is  held  up 


48  RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

by  the  monse-tootli  forceps.  As  soon  as  the  point  of  the  probe  emerges  on 
the  opposite  side  of  the  artery,  it  is  followed  np  by  an  aneurism-needle 
armed  with  a  catgut  thread,  which  is  tied  in  a  square  knot. 

Encircling  a  vessel  with  an  aneurism-needle  having  a  sharp  or  even  a  too 
slender  point  may  lead  to  piercing  of  the  artery  wall  by  the  instrument. 

Case  I. — Carl  Toiiipert,  carpenter,  aged  forty,  noticed  in  October,  1881,  a  pulsating 
swelling  on  the  left  side  of  his  neck.  By  February,  1882,  it  had  attained  the  size  of  a 
goose's  egg.  March  2d. — Ligature  of  left  common  carotid  between  the  lieads  of  the 
sterno-mastoid  muscle  at  the  German  Hospital.  In  passing  aneurism-needle  under  the 
artery  without  the  exertion  of  unusual  force,  suddenly  a  jet  of  arterial  blood  was  seen  to 
spurt  up  from  the  wound.  Traction  on  the  aneurism-needle  controlled  the  hsemorrhage. 
A  catgut  ligature  was  passed  around  the  artery  above  and  another  below  the  aneurism- 
needle,  and  both  were  tied.  The  artery  was  divided  between  the  ligatures,  and  then 
it  was  ascertained  that  the  aneurism-needle  had  made  a  longitudinal  slit  into  the 
artery  wall.  No  drainage-tube  was  used,  and  the  wound  was  closed  by  a  few  catgut 
sutures.  Pulsation  of  the  tumor  had  ceased,  and  subsequently  it  shrunk  away  to  a 
stout  cord-like  structure.  The  wound  healed  by  the  first  intention  and  no  fever 
occurred,  but  the  first  two  days  following  the  operation  very  profuse  general  per- 
spiration was  observed.     Patient  was  discharged  cured,  March  20. 

In  this  and  the  subsequent  cases,  as  well  as  in  all  other  operations  done 
by  the  author  since  1877,  catgut  was  used  exclusively  as  ligaturing  material 
with  the  greatest  satisfaction.  Only  one  case  of  suppuration  occurred  in 
which  the  infection  could  be  traced  to  the  use  of  impure  catgut  (page  8). 
Secondary  haemorrhage  or  slipping  of  the  ligature  was  observed  twice 
(page  69).  Even  in  suppurating  wounds,  catgut  has  been  found  to  be  a 
safe  ligaturing  material.  It  is  in  every  way  preferable  to  silk,  and  in  no 
case  was  its  use  ever  regretted.  Those  who  have  been  accustomed  to  tie 
vessels  with  silk,  usually  employ  too  much  force  in  tightening  catgut  liga- 
tures. They  overtax  the  strength  of  the  animal  thread,  and  to  their  great 
annoyance  constantly  break  it.  A  small  amount  of  traction  is  sufficient  to 
safely  tighten  the  knot,  as  it  is  not  necessary  nor  desirable  to  sever  the  inner 
coat  of  the  artery.  The  many  cuts,  so  common  on  the  ulnar  side  of 
surgeons'  fingers  at  the  time,  when  silk  was  generally  employed  for  tying 
vessels,  are  very  rarely  seen  nowadays.  To  preserve  its  strength,  catgut 
should  never  be  immersed  in  any  kind  of  a  watery  solution,  as  it  is  apt 
to  become  swollen  and  soft  when  brought  in  contact  with  water.  The  dish 
holding  the  ligatures  at  an  operation  should  be  dry,  or  should  contain 
absolute  alcohol. 

In  all  the  cases  here  reported,  no  drainage-tube  was  used,  reliance  being 
placed  on  natural  drainage.  The  catgut  sutures  employed  were  few  and  loose, 
and  permitted  a  free  escape  of  the  oozing  during  the  first  twenty-four  hours.. 

Primary  union  of  the  wounds  occurred  in  every  case. 

Case  II. — Herrmann  Stinze,  fishmonger,  aged  forty-six,  admitted  to  German  Hos- 
pital January  3,  1880,  with  aneurism  of  the  femoral  artery,  situated  just  underneath 
Pouparf  s  ligament,  displacing  it  forward  and  upward.  Syphilis  admitted.  Causation, 
severe  effort  at  rowing  fifteen  months  before  admission  to  hospital.  Direct  compression 
of  swelling  was  unsuccessfully  employed  for  eighty  hours.     Jan.  17th. — Deligation  of 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  49 

external  iliac  artery.  No  drainage-tube.  Catgut  suture.  Prompt  establishment  of 
collateral  circulation.  Primary  union.  Discharged  cured  February  28th.  Patient 
examined  March  28th,  when  at  the  site  of  the  aneui'ism  a  cord  of  the  size  of  the  middle 
finger  could  be  felt. 

Case  III. — Henry  Greenwald,  clerk,  aged  fifteen.  End  of  June,  1882,  sustained 
stab-wouud  of  left  palm,  followed  by  copious  haemorrhage,  which  ceased  spontaneously. 
Development  of  pulsating  swelling  of  palm,  which,  by  the  direction  of  the  family 
physician,  was  kept  tightly  compressed  with  a  leaden  bullet.  Aug.  17th. — In  the 
Oatskills  severe  arterial  haemorrhage  from  pressure-sore  over  swelling,  when  bullet  was 
removed  and  another  compressory  bandage  was  applied.  Aug.  .^O^/i.— Renewed  hasmor- 
rliage.  Esmarch's  band  being  applied,  the  clot  was  turned  out  of  the  open  sore,  the 
sac  of  the  size  of  a  hazel-nut  was  split  and  excised,  and  both  afferent  vessels  were  tied. 
Suture.     Primary  union  followed. 

Case  IV. — August  M.,  agent,  aged  forty-one,  suffering  from  progressed  ataxia, 
cut  his  ulnar  artery  August  20,  1881,  in  a  suicidal  attempt.  Haemorrhage  was  arrested 
by  pressure  made  by  a  physician  who  attended  to  the  patient  immediately  after  the 
attempt.  Aug.  23d. — Secondary  haemorrhage.  Esmarch's  band  being  applied,  the 
wound  was  dilated,  and,  the  partially  cut  artery  being  exposed,  was  doubly  tied  and  cut 
through  between.     Suture.     Primary  union. 

Case  V. — Alexander  Goerlitz,  engraver,  aged  thirty-four.  Had  chancre  eleven 
years  ago,  and  had  been  in  the  habit  of  folding  his  legs  while  at  work.  Jmie,  1883. — 
Noticed  pulsating  swelling  in  right  popliteal  space.  Sejyt.  15th. — Circumference  of 
left  knee,  thirteen,  of  right  knee,  sixteen  and  a  quarter  inches.  Knee  semi-flexed. 
Skin  over  aneurism  dusky  and  hot.  Esmarch's  constrictor  applied  above  and  below 
swelling  for  an  hour  under  ether  without  success,  circumference  increasing  to  seven- 
teen and  a  quarter  inches.  Sept.  19th. — Ligature  of  right  superficial  femoral  artery  in 
middle  of  thigh.  Sept.  21st. — Swelling  hard,  non-pulsating.  Paralysis  of  dorsal 
flexors  of  foot  and  of  extensors  of  toes.  No  necroses.  Primary  union.  May  17,  I884. 
— Knee  can  be  fully  extended,  paralysis  disappeared,  muscles  of  leg  have  regained  their 
normal  bulk,  tumor  shrunken  to  a  small,  hard  mass. 

Case  VI. — August  Bente,  cigar-maker,  aged  fifty-one.  No  syphilis.  In  the  sum- 
mer of  1883  felt  neuralgic  pains  in  right  arm,  followed  by  wasting  of  the  brachial 
muscles,  cyanosis,  formication,  and  hyperidrosis  of  the  extremity.  In  December 
severe  dyspnoea  supervened,  and  a  pulsatile  swelling  under  the  right  sterno-clavicular 
junction  and  in  the  lower  cervical  triangle  was  made  out  by  Dr.  John  Schmidt,  who 
directed  the  patient  to  the  author,  then  on  duty  at  the  German  Hospital.  Aneurism 
of  the  innominate  and  subclavian  arteries  at  their  junction  was  diagnosticated,  and 
simultaneous  ligature  of  the  right  common  carotid  and  the  axillary  arteries  was  per- 
formed January  16,  1884.  The  latter  vessel  was  tied  in  Mohrenheim's  triangle,  just 
below  the  outer  third  of  the  clavicle.  No  drainage-tubes  ;  suture.  Immediately  after 
the  operation  the  pulsation  of  the  swelling  became  more  pronounced,  and  for  the  next 
four  weeks  the  shooting  pains  in  the  arm  were  much  complained  of.  Both  wounds 
healed  by  primary  intention.  Toward  the  end  of  February  decrease  of  the  swelling 
and  moderation  of  the  subjective  symptoms  became  manifest.  'In  March  and  April 
thirty  hypodermic  injections  of  Bonjean's  ergotine  were  made  in  the  abdominal  region, 
and  seemed  to  hasten  the  shrinking  of  the  tumor.  By  May,  the  cyanosis,  sweating, 
glossy  skin,  and  formication,  as  well  as  the  neuralgic  symptoms,  had  very  much  abated, 
and  the  patient  had  gained  ten  pounds  of  flesh.  Under  massage,  the  application  of 
faradism,  and  active  exercise,  the  atrophy  of  the  muscles  had  also  materially  improved, 
and  in  June  the  patient  could  resume  his  occupation.  JSTov.  11,  1884- — Patient  was 
presented  to  the  Surgical  Society.     Pulsation  had  almost  entirely  disappeared,  and 


50  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGEEY. 

wliat  there  was  of  it  seemed  to  be  transmitted.  Bruit  was  not  noticeable.  A 
well-perceptible  fullness  and  resistance  could  still  be  made  out  in  the  right  supra- 
clavicular fossa.  Occasionally  short  and  mild  attacks  ot  shooting  pains  were  felt 
in  the  arm  and  nape  of  the  neck.  A  claw-like  deformity  of  the  nails  of  the  right  hand 
remained  unaltered.  In  August,  pulsation  and  other  signs  of  relapse  were  noted, 
with  increasing  pain,  radiating  toward  the  occiput.  Renewed  injections  of  ergot  were 
without  avail.  In  October,  during  the  author's  absence  from  town,  Dr.  Adler  incised 
an  abscess  pointing  in  the  supraclavicular  space,  and  a  few  days  later  performed  tra- 
cheotomy for  threatening  asphyxia.  A  sharp  pneumonia  followed,  from  which  the 
patient  recovered  only  to  succumb  in  November  to  sudden  suffocation.  No  autopsy 
was  permitted. 

Case  VII. — John  H.  Mttinger,  grocer,  aged  forty-five.  No  syphilis;  had  had 
articular  rheumatism  seven  years  before.  Pulsating  swelling  of  left  popliteal  space  of 
the  size  of  a  man's  fist.  Leg  had  been  oedematous  for  three  months;  marked  emacia- 
tion. Jan.  SO,  1885. — Ligature  of  left  femoral  artery  in  Scarpa's  triangle.  Primary 
union  of  wound.  Recovery  retarded  by  circumscribed  necrosis  of  integument  over 
tuberosity  of  calcaneum  (due  to  pressure?).     Discharged  cured,  March  30,  1885. 

Case  VIII. — Emmanuel  Luecke  (see  history  on  page  172). 

Case  IX. — Robert  Klaile,  school-boy,  aged  fourteen.  Congenital  arterio-phlebec- 
tasia  of  anterior  part  of  left  foot ;  pulsating,  dusky  swelling,  of  doughy  feel,  of  dorsum 
and  planta  pedis.  Along  the  course  of  saphenous  nerve  were  seen  a  series  of  flat,  hard, 
dark-blue,  rough  nodes,  some  of  them  as  large  as  a  silver  .quarter,  their  size  tapering 
off  toward  ankle.  Two  of  them  were  ulcerated  and  covered  by  a  dry  scab.  Left  foot 
on  the  whole  larger  than  its  mate.  Pulsation  of  femoral  arteries  abnormally  strong. 
Heart  hypertrophied.  Ablation  of  diseased  parts  was  declined.  July  7,  1885. — Liga- 
ture of  superficial  femoral  artery.  Short  stoppage,  and  return  of  pulsation.  Imme- 
diate ligature  of  external  iliac  of  same  side.  Wounds  sutured ;  no  drainage.  Primary 
union.  Necrosis  of  terminal  phalanges  of  first  and  second  toes,  of  the  integument  of  the 
external  side  of  leg,  and  of  peroneus  longus  muscle.  Scanty  aseptic  suppuration,  and 
very  slow  detachment  under  antiseptic  dressing.  Tardy  cure.  The  cicatrices  on  the 
toes  became  ulcerated  in  the  winter,  and  the  pulsation  of  the  tumor,  which  had  not 
diminished  in  size,  had  returned.  Jan.  S9,  1886. — Pirogoff's  amputation.  Unusual 
number  of  ligatures  required  on  account  of  many  abnormally  large  arteries.  Cap  of 
calcaneum  was  fixed  to  tibia  by  steel  nail  driven  through  from  below.  Catgut  suture. 
Drainage  through  counter-incision  alongside  of  tendo  Achillis.  No  fever.  First 
change  of  dressings  February  19th.  Primary  union  throughout,  except  where  a  narrow 
strip  of  the  integument  had  necrosed  along  anterior  part  of  incision.  Dry  dressing. 
Feb.  SJfth. — All  firmly  healed.     Patient  walks  well  without  support. 

Note. — In  exposing  the  external  iliac  artery,  the  small  group  of  lymphatic  glands  found 
underneath  the  transversalis  fascia,  just  above  Poupart's  ligament,  may  serve  as  an  unfailing 
guide.  As  soon  as  these  glands  come  to  view,  the  peritoneum  can  be  stripped  up  without  diffi- 
culty. In  incising  a  deeply  situated  perityphlitic  abscess,  the  same  glands  serve  as  a  good  land- 
mark to  prevent  the  operator  from  cutting  into  the  fascia  of  the  ilio-psoas  muscle,  which  would 
divert  him  under  the  vessels. 

II.     EXTIRPATION    OF    TUMORS. 

In  removing  tumors  three  requirements  have  to  be  commonly  held  in  view : 
First,  the  avoidance  of  septic  infection  from  without  or  from  within. 
iSecondly,  the  complete  removal  of  the  neoplasm. 
Thirdly,  its  safe  removal. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


51 


Fig.  34:. — Gluteal  tumor  belore  extirpation. 


How  to  avoid  infection  from  without  was  seen  in  previous  chapters  of 
this  book.     By  infection  from  within,  two  kinds  of  infection  are  meant. 

One  is  the  contamination  by  septic  contents  of  the  tumor  that  may  escape 
into  the  wound  through  an  accidental  cut  or  a  laceration  of  the  tumor, 
caused  by  rough  handling  or 
the  careless  use  of  sharp  re- 
tractors, as,  for  instance,  in  ex- 
tirpating suppurating  glands. 

Case. — Sarah   Barn,  servant, 

aged  sixteen;    old  Pott's  disease 

of  the   cervical   vertebrae ;    large 

glandular  swelling  of  right  sub 

maxillary  reaion,  with  several  si- 
nuses leading  cown  toward   the 

spine.     It  was  pretty  certain  that 

no  serious  degree  of  the  affection 

of  the  vertebrae  could  be  present, 

as  the  function   of  the   cervical 

spine  was  nearly  normal.    Xovem- 

her  Jfi   18S6. — Flap   incision    and 

exsection   of  the    large   mass   of 

tubercular  glands  at  Mount  Sinai 

Hospital.   Though  the  utmost  care 

was  exercised  in  not  grasping  the 

glands  with  sharp-pointed  instruments,  one  of  them  broke  down,   and  poured  out 

its  contents  into  the  large  wound.     As  subsequent  events  demonstrated,  seemingly 

thorough  irrigation  with  a  strong  solution  of  corrosive  sublimate  did  not  disinfect  all 

the  parts  of  the  wound.     The  dissection  mainly  extended  into  the  intermuscular  space 

— namely,  the  slit  between  the  scaleni  and  the  posterior  border  of  the  sterno-mastoid. 

iifter  the  removal  of  the  mass,  the 
finger  was  easily  inserted  into  a 
track  leading  toward  the  second 
vertebra,  the  anterior  surface  of 
which  was  found  rough  and  bare 
of  periosteum.  It  was  thoroughly 
scraped  and  irrigated  (the  instru- 
ment could  be  felt  in  situ  from  the 
oral  cavity) ;  the  outer  wound  was 
drained,  sutured,  and  dressed.  Xov. 
5th. — High  fever,  with  much  de- 
jection. Skin  below  ear  red,  pain- 
ful, and  swollen.  The  flap  was  re- 
opened, and  a  small  abscess  was 
detected  just  under  the  base  of  the 

flap,  where  probably  irrigation  had  been  insuflicient.     Open  treatment.     Temperature 

fell  off  to  normal  at  once.     The  patient  was  discharged  cured  December  1st. 

The  other  kind  of  infection  is  the  dissemination  through  the  lymphatics 
of  cancerous  or  sarcomatous  cell-elements  into  the  body  caused  by  pressure 
due  to  rough  manij^ulation  of  the  tumor. 


¥iG.   35. — Gluteal  dressiiii;-. 


52  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Note. — It  is  a  well-known  fact  that,  in  some  cases  of  malignant  tumor  of  slow  growth,  after 
operation,  a  large  number  of  secondarj'  nodes  will  spring  up  and  develop  with  great  rapidity  in 
the  neighborhood  of  the  cicatrix.  Two  causes,  either  singly  or  combined,  may  be  at  the  bottom 
of  this  phenomenon. 

Either  the  operation  was  incomplete — that  is,  the  surgeon's  dissection  hugged  the  tumor 
too  closely,  leaving  behind  a  number  of  outstanding  microscopical  foci, — or  the  forcible  manipu- 
lations of  the  tumor  during  the  operation  have  disseminated  along  the  lymphatics  and  veins 
embryonal  cell-elements  of  malignant  character  into  the  vicinity  of  the  wound  or  throughout  the 
body.  This  is  commonly  called  "  change  of  the  character  of  a  malignant  neoplasm,  due  to 
mechanical  irritation." 

Undoubtedly  there  are  many  cases  where  an  incomplete  operation  leads  to  wide  dissemina- 
tion of  the  elements  of  the  neoplasm.  In  these  cases  relapse  in  the  unhealed  wound  or  in  the 
fresh  cicatrix  is  observed,  together  with  the  simultaneous  appearance  of  regional  and  more  dis- 
tant nodes  of  new  formation. 

Thus  an  incomplete  or  rough  operation  may,  by  generalization  of  the  disease,  hasten  instead 
of  retarding  the  patient's  death. 

Eeasonable  hope  of  the  complete  removal  of  a  malignant  new-growth  is 
the  main  justification  for  operative  interference.  There  is,  to  be  sure,  a 
considerable  class  of  cases  where  complete  removal  is  from  the  outset  out 
of  the  question.  Great  discomfort  from  putrescence  of  a  sloughing  tumor 
or  frequent  haemorrhages  do  sometimes  indicate  partial  removal.  But, 
wherever  possible,  comi^lete  removal  is  to  be  aimed  at  by  all  permissible 
means,  as  the  non-return  of  the  disease  depends  solely  upon  the  fulfillment 
of  this  condition. 

Our  third  object  must  be  to  remove  the  tumor  with  the  least  possible 
amount  of  immediate  danger  to  the  patient's  life.  Careful  and  deliberate 
dissection,  guided  by  anatomical  knowledge,  limiting  of  the  haemorrhage 
to  a  minimum,  and  avoidance  of  accidental  injury  to  important  organs,  is 
meant  hereby. 

The  most  important  condition  to  be  fulfilled  in  eschewing  these  dangers 
is  an  adequate  incision. 

A  too  large  incision  never  can  do  any  harm,  its  worst  consequence  being 
the  necessity  for  a  few  more  suture-points.  An  insufficient  incision,  on  the 
other  hand,  may  be  the  source  of  great  danger  to  the  patient,  and  of  much 
embarrassment  to  the  surgeon. 

When  the  incision  is  ample,  the  new-growth  and  its  connections  can  be 
readily  exposed  without  the  use  of  much  traction  from  sharp  or  blunt  hooks, 
and  forcible  grasping  and  dragging  to  and  fro  of  the  tumor  itself  will  be 
unnecessary.  Most  of  the  vessels  that  are  to  be  divided  will  be  noticed,  and 
can  be  cut  between  two  artery  forceps  without  loss  of  blood.  Accidentally 
injured  vessels  can  be  easily  secured  and  tied  off. 

The  wretched  expedient  of  digging  a  malignant  tumor  out  of  its  capsule, 
and  leaving  behind  the  latter,  should  never  be  resorted  to,  as  a  si)eedy' 
relapse  is  certain  to  follow. 

Dissection  should  be  done  altogether  with  the  knife,  and  exclusively 
in  healthy  tissues.  Blunt  methods  of  preparation  are  not  to  be  used  at 
all,  since  they  are  unnecessary,  and  involve  a  certain  amount  of  rough 
force. 


SPECIAL  APPLICATION   OF  THE   ASEPTIC  METHOD. 


53 


t"iG.  ?AJ. — Axillary  tuiuor  before  extirpation. 


In  removing  infiltrating  or  illy  doiined  malignant  new-growths,  the  sur- 
geon's knife  should  give  the  tumor  a  wide  berth,  and  all  cosmetic  or  func- 
tional considerations  not  involving  present  danger  should  be  disregarded, 
the  first  object  being  the  complete  eradication  of  the  disease. 

In  an  ample  wound  the  tu- 
mor can  be  handled  with  the  ne- 
cessary gentleness,  and  the  main 
attack  can  be  directed  upon  its 
adhesions  to  the  surrounding  tis- 
sues. 

With  rare  exceptions,  sharp  re- 
tractors are  never  to  be  plunged 
into  the  tumor.  They  should  be 
used  on  the  edges  of  the  wound 
for  dilatation,  the  tumor  itself 
being  held  by  hand  through- 
out. 

The  softer  the  mass  of  the  tu- 
mor, the  more  care  must  be  exer- 
cised not  to  -injure  it.  Cysts  especially  require  very  tender  treatment. 
Lipomata  and  fibromata  will  stand  a  good  deal  of  rough  handling  with- 
out harm. 

Note. — In  former  days  lipomata  used  to  have  a  bad  reputation.     It  was  said  tiiat  their 

extirpation  was  often  followed  by  erysipelas  and  phlegmon.     One  of  the  first  operations  ever 

witnessed  by  the  author  was  done  upon  a  healthy  young  man  in  1868  in  Prof.  D.'s  clinic,  at 

Vienna,  for  a  lipoma  of  the  shoulder.     It  caused  the  patient's  death 

from  septicaemia.     This  peculiarity,  noted  by  surgeons  in  times  gone 

by,  was  undoubtedly  due  to 
the  readiness  with  which  a 
phlegmonous  process  will 
spread  in  loose  and  ill-nour- 
ished adipose  tissue.  Of 
course,  the  infection  always 
came  from  the  hands  and 
apparatus  of  the  surgeons 
themselves. 

Where  sJiotild  dis- 
section first  be  direct- 
ed to,  is  a  question 
that  puzzles  every  be- 
ginner, and  it  is  not  in- 
different from  which 
side   "we    approach    a 

tumor.     Surgery  owes  to  Langenbeck  a  clear  exposition  of  the  principle 

which  should  guide  us  in  this  matter. 

In  excising  tumors  liolding  close  relations  to  large  vessels,  as,  for  instance, 

those  in  the  neck,  axilla,  and  in  Scarpa's  triangle,  the  greatest  safety  lies  in 


Fig.  3T. — Axillary  wound,  united,  after  e.xtirpation  of  tumor. 


54 


RULES   OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 


first  exposing  these  vessels  above  and  below  the  tumor,  so  as  to  have  full  con- 
trol of  them  during  the  subsequent  steps  of  the  operation.  This  precaution 
offers  great  security  against  injury  of  those  vessels,  and  at  the  same  time 

reduces  to  a  minimum 
the  otherwise  formida- 
ble dangers  of  such  ac- 
cidental injury,  should 
it  occur.  If  it  become 
evident  that  the  tu- 
mor has  involved  the 
walls  of  the  adjacent 
large  vessels,  a  ligature 
above,  another  below 
the  growth,  will  per- 
mit of  a  safe  and  com- 
plete exsection  in  one 
mass  of  the  tumor  and 
the  diseased  parts  of 
the  vessel. 


Fig.  38.- — Flap  incision  for  removal  of  tumor  of  neck, 
drained  and  sutured. 


Wound 


Note. — It  is  the  common  tendency  of  young  surgeons  to  carry  too  far  the  dissection  of 
a  vessel  adhering  to  a  tumor.     This  is  actuated  by  the  desire  of  preserving  the  integrity  of  the 

vessel  in  question,  and  by  the  natural  disinclination 
of  complicating  the  operation  by  double  ligature, 
which  again  involves  extra  dissection.  The  con- 
sequence of  this 
tendency  may  be 
twofold  :  either 
portions  of  the 
tumor  adhering 
to  the  vessel  wall 
are  left  behind  to 
cause  speedy  re- 
lai)se,  or  the  vein 
is  cut  or  torn. 


Fjg.  'M.—  iJrc.-s.^ing  lor  neck  vvound.s. 


40. — Dres.sing  of  neck  wound  completed 
by  rubber-tissue  bib  and  ami-sling. 


SPECIAL   APPLICATION   OF  THE  ASEPTIC   METHOD. 


55 


Wheneve?-  the  surgeon  has  succeeded  in  forminfj  a  pedicle  to  a  tumor  situ- 
ated in  tlie  vicinity  of  largo  vessels,  cuttimj  of  such  a  pedicle  without  first 
tying  it  off  is  a  very  risky  step.  Traction  upon  the  tumor  will  obliterate 
any  vessels  included  in  the  pedicle,  and,  when  cut,  the  innocent-looking 
mass,  closely  resembling  ordinary  connective  tissue,  may  open  up  into  unex- 
pected and  overwhelming  springs  of  welling  blood.  The  stump  will  at  once 
retract,  and  finding  and  securing  the  retracted  vessel  in  an  inexhaustible 
pool  of  blood  is  a  terribly  difficult,  sometimes  impossible,  thing.  Should  it 
be  an  arter}^,  the  tips  of  two  or  three  fingers  must  be  thrust  at  once  into  the 
place  from  which  the  haemorrhage  is  issuing.  The  blood  must  be  mopped 
up  by  rapid  sponging,  to  enable  the  surgeon  to  find  the  vessel,  in  order  to 
secure  it  with  an  artery  forceps,  or  to  surround  it  by  a  suture  passed  through 
the  adjacent  tissues.  His  mettle  will  be  put  to  the  severest  test,  and  it 
will  be  a  lucky  day  if  his  patient  do  not  succumb  on  the  table. 

In  trying  to  secure  the  stump  of  a  large  vein  accidentally  cut  across,  the 
wide  extent  of  its  circumference  will  offer  much  difficulty,  as  an  ordinary 
artery  forceps  is  too  small  to  take  in  the  entire  lumen  of  the  vessel.  One 
or  more  great  leaks  will  remain,  even  if  the  vessel  be  fortunately  grasped  by 
one  forceps.  Two,  three,  or  more  additional  instruments  have  to  be  brought 
into  requisition  till  the  end  is  accomplished.  The  haste,  natural  and 
almost  unavoidable  on  such  occasions,  will  easily  lead  to  further  tearing  of 
the  soft  walls  of  the  vessel,  and,  finally,  salvation  will  have  to  be  sought  in 
plugging  with  iodoform  gauze. 

Here,  like  in  other  things,  prevention  is  much  easier  than  cure. 

Lateral  tearing  or  slitting  of  a  large  vein  is  another  accident  to  which 
may  lead  disregard  of  Langenbeck's  rule.  There  are  two  ways  out  of  this 
contingency.  One  is  to  expose  and  deligate  the  vein 
above  and  below  the  laceration,  while  the  fingers  of  an 
assistant  compress  the  injured  part  of  the  vessel.  The 
other  one  is  the  application  of  a  lateral  ligature  or  a  con- 
tinuous suture  of  fine  catgut  occluding  the  rent. 

Both  of  these  latter  methods,  however,  are  difficult 
and  not  very  reliable,  though  they  have  succeeded  in  the 
hands  of  several  surgeons,  including  the  author's.* 

They  were  bred  of  the  fear  of  tying  large  veins,  for- 
merly so  prevalent  on  account  of  the  dangers  of  phlebitis 
and,  in  the  extremities,  of  gangrene.  In  cases  where  a 
large  portion  of  the  vein  wall  is  lost  by  sloughing  or  cut- 
ting, and  the  resulting  aperture  is  very  large,  lateral  liga- 
ture and  suture  are  impossible.  Whenever  feasible,  a 
double  ligature  should  be  applied,  whether  it  concerns  the  deep  jugular  or 
axillary  and  femoral  veins.  Langenbeck's  advice  to  tie  the  accompanying 
large  artery  has  been  much  impugned  lately,  as  it  was  found  that  gangrene 

*  In  a  case  of  exsection  of  lymphomata  of  the  neck,  done  in  1880  in  the  German  Hospital, 
where  the  deep  jugular  was  injured.     The  patient  recovered. 


Fig.  41. — Lateral  lig- 
ature and  continu- 
ous suture  of  in- 
jured vein. 


56 


RULES  OF  ASEPTIC  AND   ANTISEPTIC   SURaERY. 


of  the  extremity  followed  its  adoption.  On  the  other  hand,  a  growing  num- 
ber of  cases  are  on  record,  where  deligation  of  the  femoral  or  axillary  vein 
led  only  to  temporary  disturbance  of  no  great  import. 

Case. — Henry  Rickriegel,  carpenter,  aged  twenty-three,  admitted  to  German  Hos- 
pital, March  2.  1887.     Two  days  later  the  house-surgeon  extirpated  a  mass  of   sup- 
purating glands  from  Scarpa's  triangle  of  the  right  side.   The 
saphenous  vein,  which  passed  into  the  tumor  from  below, 
was  tied  and  cut  across.     Likewise  were  treated  a  number 
of  larger  veins  entering  the  tumor  from  above.     The  femoi  al 
vessels  were  not  exposed,  but  the 
pulsation  of  the  artery  could  be 
distinctly  felt,  and  it  was  care- 
Finally,    the 


42. — Periosteal  myxosarcoma  of  thigh  before  removal. 


mass  was  freed  all  around,  until  a  stout  pedicle  was  formed,  which  was  seen  entering 
the  oval  foramen  of  the  fascia  lata.  This  pedicle  was  tied  with  catgut  and  was  cut 
through.  In  the  mean  time  the  patient  had  be- 
come semi-conscious  and  began  to  struggle,  where- 
upon, suddenly,  an  enormous  jet  of  venous  blood 
was  seen  to  well  up  from  the  bottom  of  the  wound. 
The  operator  plunged  his  fist  into  the  pool  of 
blood,  and  thus  succeeded  in  checking  the  hsemor- 
rhage  until  Dr. 
Bachmann,  the 
chief  of  the  house- 
staff,  appeared, 
who  luckily  suc- 
ceeded, with  the 
aid  of  Thiersch's 
spindles,  in  pass- 
ing two  ligatures, 
one  below,  the 
other  above  tlie 
bleeding  point,  ef- 
fectually stopping 
tlie  formidable 
loss  of  blood.  Im- 
mediately,     deep 

cyanosis  and  oedema  of  the  lower  extremity  developed,  and  the  author,  who  saw  the 
patient  directly  after  the  operation,  ordered  elevation  of  tlie  limb,  which  was  brought 
atiout  by  its  vertical  suspension  in  a  wire  cradle.     March  5th. — C'yanosis  disappeared. 


Fiii.   i'j.  —  I'liitcd   wound    after  reiuoval  oi  luy.xo.sareoma  of  tliigli. 


SPECIAL   APPLICATION   OF  THE   ASEPTIC   METHOD. 


57 


oedema  rnucli  dimiuished.  Temperature.  Iur5°.  Circulation  of  limb  good.  The 
wound  did  well,  but,  March  18tli,  temperature  rose  to  103°  Fahr.,  and  signs  of  phlebitis 
of  the  femoral  vein  in  tiie  middle  of  the  thigh  appeared  in  the  shape  of  a  cylindrical, 
painful,  and  hard  infiltration.  This  and  a  number  of  similar  attacks  were  snbdued  by 
the  application  of  an  ice-bag.  The  persistent  cedema  was  combated  by  elastic  com- 
pression with  Martin's  bandage,  supplemented  later  on  by  massage.  May  15th. — The 
patient  wjis  discharged  cured,  very  little  of  the  oedema  being  still  noticeable. 

Ill  this  ease,  apparently,  a  portion  of  tlie  trunk  of  the  femoral  vein  was 
drawn  into  the  cone  of  the  pedicle  containing  the  root  of  the  saphenous 
A'eiu.  and  was  excised  along  with  the  tumor. 

The  ligature  slipped  off,  and  a  wide  ga]-)  was  opened  in  the  side  of  the 
femoral  vein  corresponding  to  the  place  of  entrance  of  the  sapheua.  The 
peculiarity  of  the  walls  of  large  veins  to  yield  to  lateral  traction  is  well 
known  to  surgeons,  and  is  a  just  source  of  anxiety,  as  the  extended  vein 
becoming  empty  can  not  be  recognized. 

Double  ligature  of  the  vein  will  be  insufficient  to  check  the  ha?morrhage 
when  a  large  branch  inosculates  between  the  two  ligatures.  Such  branch 
must  be  separately  exposed  and  tied. 

Case. — March  2T,  1880.  the  surgeon  in  charge  of  the  ward  for  syphilis  and  skin 
diseases  at  the  German  Hospital  excised  a  large  glandular  tumor  from  Scarpa's  tri- 
angle on  John  Te  Gempr.  aged  twenty-four.     The 
•ation  was  finished  without  accident,  and,  ae- 
ing  to  the  then  prevailing  custom,  the  wound 
mopped  with  an  eigbt-per-cent  solution  of  cHo- 
of  zinc.     April  11th. — A  large  slough  of  the 
vein  wall  was  detached,  and  fear- 
ful hfemorrhage  ensued,  which 
Dr.  Loewenthal,  the  house-sur- 
geon, could  not  check  complete- 
ly by  local  pressure.    When  the 
author  saw  the  patient,  be  was 
nearly    exsanguinated,    though 
conscious.     No  pulse  could  be 
felt.     Without    anfesthesia  the 
femoral  vein  was  exposed  below 
the  opening  in  its   wall,  while  pressure   by  three  finger-tips   completely   controlled 
the  haemorrhage. 

XoTE. — Thrusting  of  the  fist  or  of  a  sponge  into  the  wound  will  not  cheek  ha?morrhage 
effectually  m  these  cases.  The  tips  of  the  fingers  pressed  exactly  upon  the  bleediug  orifice,  and 
without  much  force,  will  always  succeed  in  controlling  the  vessel. 

As  the  vein  bled  from  above,  too,  Ponpart's  ligament  was  cut  across,  and  the  external 
iliac  vein  was  tied.  After  this  the  loss  of  blood  became  very  much  diminished,  but  a 
considerable  vein  inosculating  just  opposite  the  defect  in  the  wall  of  the  femoral  vessel 
required  separate  exposure  and  deligation,  whereupon  the  haemorrhage  ceased  com- 
pletely. Unfortunately,  the  total  loss  of  blood  had  been  so  considerable  that  the  patient 
survived  the  operation  only  a  short  time,  and  died  in  collapse  from  acute  anaemia. 

Deligation  and  partial  exsedion  of  the  axillary  vein  for  ingrowing  cancer 
of  the  axillary  glands  has  been  often  performed  by  various  surgeons  with 


ua  of  thiirh. 


58 


RULES   OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 


entire  success,   and   can  be  iindertahen  without  hesitation   whenever  un- 
avoidable. 

In  (Ungating  the  deep  ^jugular  vein,  avoidance  of  the  jmeumogastiHc  nerve 
will  require  close  attention.  AVhen  there  is  enongli  space  to  expose  and 
liberate  the  vein  freely,  this  will  not  Ije  found  very  difficult.  Low  down  at 
the  root  of  the  neck  however,  the  decision  of  the  question  whether  the 
lipiture  encompasses  the  nerve  or  not  may  occasionally  be  impossible. 

Case. — Mrs.  Catharine Plunkett,  aged  sixty-four.  Extirpation  of  recurrent  hmpho- 
sarcoma  of  neck,  December  22,  1886,  at  Mt.  Sinai  Hospital.  A  tumor  of  the  size  of 
a  hen's  egg  was  located  low  down  in  the  supra-clavicular  fossa.  Though  it  was  freely 
movable,  its  close  relation  to  the  large  cervical  vessels  was  anticipated.  A  flap  incis- 
ion and  careful  dissection  laid  bare  the  jugular  vein  above  and  below  the  tumor,  when 
it  became  evident  that  it  would  be  impossible  to  remove  it  without  excising  a  correspond- 
ing portion  of  the  vein.  The  lower  ligature  had  to  be  applied  somewhat  behind  the 
sterno-clavicular  rim,  and  on  account  of  the  lack  of  space  this  was  very  difficult.  Isola- 
tion of  the  vein  had  to  be  done  with  the  greatest  caution  to  avoid  its  injury.  Finally 
a  silver  probe  wormed  its  way  around  the  vein,  and  the  question  arose,  "Was  or  was 
not  the  pneumogastric  nerve  included  in  the  ligature?  To  test  this  the  thread  was 
firmly  tied  in  a  single  knot.  No  change  whatever  of  the  respiration  or  pulse  being 
noted,  it  was  assumed  that  the  nerve  was  not  caught,  whereupon  a  double  ligature  was 
passed  through  by  means  of  the  first  thread,  and,  being  tied,  the  vein  was  cut  across. 
But  on  inspection  of  the  mass  it  became  clear  that  the  nerve  was  included  in  the  liga- 
ture and  had  been  cut  through.  The  tumor  was  easily  dissected  up  after  this  until  a 
pedicle  was  formed  containing  the  jugular  vein  from  above.  This  being  tied,  the 
tumor  was  removed.  Drainage,  suture,  and  dressings  were  applied  in  the  usual 
manner.  The  patient  recovered  without  one  untoward  symptom.  Dec.  31st. — The 
first  dressing  was  removed,  together 
with  the  drainage-tubes.  Jan.  3, 
1887. — She  was  discharged  cured. 

Having  thus  gone  through 
the  entire  subject,  we  may  sum 
up  in  the  following  points  : 

To  accomplish  a  thorougli  and 
at  the  same  time  safe  removal  of 
a  tumor  located  in  the  vicinity 
of  large  vessels,  an  adequate,  that  is,  very  ample,  in- 
cision is  absolutely  necessary. 

a  h 


/ 


Fig.  45.— Outlines  of  flu] 
incisions. 


NoTK. — On  the  trunk  and  the  exti'cmitie.s,  straiglit  incision.",  with 
the  addition  of  a  transverse  extension,  will  be  found  most  convenient. 
Where  a  transverse  cut  is  inopportune,  considerable  gain  in  space  can 
be  effected  by  undulatiny  the  line  of  incision. 

In  Scarpa's  triangle,  hut  especially  about  the  neck,  flap  incisions  are  the  most  convenient. 


Fig.  40.— a.  T-shaped 
incision.  //.  Undu- 
latmg  incision. 


Methodical  dissection,  guarded  by  as  many  preliminary  double  ligatures 
as  necessary,  will  insure  a  steady  and  uninterrupted  progress  of  the  opera- 
tion. Loss  of  blood  will  be  minimal,  and  the  flurry  and  haste  incumbent 
upon  profu.se  accidental  hieniorrhage  will  not  lead,  as  it  always  does,  to  the 
disregard  of  the  rules  of  asepticism. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  59 

Aseptic  canons  arc  easily  forgotten  durinfi^  fi-antic  etrorts  to  ciieck  dan- 
gerous hiuniorrluigc,  although  it  is  conceded  tiiat  avoidance  of  sup})urati()n 
is  all  the  more  important  because  of  the  injury  to  large  vessels. 

After  thorougli  irrigation  and  cleansing,  the  drainaga  of  tlio  cavity  is 
to  be  attended  to.  It  should  he  direct — that  is,  should  reach  the  surface 
on  the  shortest  possible  route,  if  necessary  through  a  counter-incision — aiul 
care  must  be  taken  of  not  letting  the  square  inner  end  of  the  tube  impinge 
upon  a  large  artery.  Especially  must  this  point  be  heeded,  where  the  tube 
consists  of  hard  material,  as  perforation  of  the  vessel  by  friction  against  the 
hard  edge  of  the  tube  is  possible. 

Note. — Tlicre  are  cases  on  record  where  the  iiiiiomhiate  was  ulcerated  through  by  friction 
pressure  of  the  iiiargiu  of  a  tracheotomy  caiiiiuUi. 

The  inner  eiul  of  the  tube  should  be  placed  so  as  not  to  touch  the  vessels. 
the  general  direction  of  the  mesial  end  of  the  tube  being  parallel  with  them. 
To  secure  this  position  the  inner  end  of  the  tube  should  be  fastened  to  a 
suitable  i)art  of  muscle  or  fascia  by  a  catgut  stitch. 

Cliange  of  dressings  will  be  required,  according  to  the  size  of  the  tumor, 
on  fi'om  the  sixth  to  the  tenth  day,  when  the  tubes  can  be  withdrawn. 

III.     AMPUTATION    OP    LIMBS. 

In  performing  a  major  amputation,  the  modern  surgeon  has  to  solve 
three  problems : 

The  first  is  to  avoid  septic  infection  of  the  amputation  wound,  or,  if 
sepsis  of  the  limb  be  present,  to  eliminate  it. 

The  second  one  is  to  limit  hsemorrhage  to  an  unavoidable  minimum. 

The  third  problem  is  to  secure  a  good  stump. 

1.  Aseptics  and  Antiseptics  of  Amputation. — To  the  adoption  of  aseptic 
and  antiseptic  measures  must  be  ascribed  the  remarkable  reduction  of  the 
rate  of  mortality  after  major  amputations,  now  prevalent  wherever  such 
measures  are  practiced.  Formerly  one  third  of  all  cases  were  directly  lost 
mainly  through  primary  septicaemia,  or  pygemia,  or  indirectly  by  secondary 
haemorrhage  due  to  ulcerative  destruction.  At  present,  deaths  from  acute  and 
chronic  blood-poisoning  or  secondary  haemorrhage  are  very  rare,  and  limited 
to  cases  that  come  under  the  surgeon's  knife  in  a  neglected  or  septic  state. 

The  total  mortality,  as  computed  from  nearly  1,000  unselected  hospital 
cases  of  various  surgeons,  treated  on  the  new  plan,  is  about  fifteen  per  cent. 

The  author's  personal  experience  embraces  forty-three  cases  of  major 
amputation,  mostly  done  in  hos])ital  practice.     These  were  : 

Amputations  of  the  thip;h 22 

"     "    leg V 

"     "    foot V 

"            "     "    shoulder 1 

"            "     "    arm 3 

"             "     "     forearm 3 

Total 43 


60  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SUEGERY. 

The  amputations  were  performed  : 

For  suppurating  compound  fracture  in 2  cases 

"    phlegmon  in   t3     " 

"    acute  and  chronic  osteomyelitis  in 6     " 

"    spontaneous  gangrene  in 5     " 

"    incurable  ulcers  in 5     '' 

"    articular  tuberculosis  in 12     " 

"    phlegmon  from  uratic  arthritis  in   1  case 

"    malignant  new-growths  in 6  cases 

Total 43     " 

Of  this  number  were  cured  : 

By  primary  union 16  oases 

"    partial  adhesion 14 

With  suppuration 8 

Cured o8 

Died 5 

Total 43 

The  five  fatal  cases  were  as  follows  : 

Case  I. — Max  LoflFmann,  Araputation  of  thigh  at  Mount  Sinai  Hospital  for 
secondary  haemorrhage  due  to  phlegmon  of  popliteal  space  after  exsection  of  knee. 
Patient  came  on  table  collapsed,  and  died  immediately  after  ablation  (see  page  245). 

Case  11. — Giistav  Leuber,  aged  forty-nine.  March  22,  1883. — Syme's  amputation 
of  foot,  at  the  German  Hospital,  for  tuberculosis  of  tarsus.  Died  May  5,  1883,  of  gen- 
eral marasmus,  due  to  pulmonary  tuberculosis.     Wound  nearly  healed. 

Case  III. — Carl  Frank,  aged  sixty.  Senile  gangrene  of  foot  and  leg ;  amputated  at 
the  German  Hospital.  On  account  of  the  collapsed  and  septic  condition  of  the  patient, 
twenty  ounces  of  a  six-pro-mille  saline  solution  were  transfused  before  commencing  the 
amputation.  The  pulse  rallied,  and  transcondylic  amputation  was  done,  but  patient 
died  immediately  after  the  bone  was  sawed  oif. 

Case  IV. — Louis  Bourbonus,  carpenter,  aged  twenty-nine.  Acute  progressive 
gangrenous  phlegmon  of  hand  and  forearm.  Septicaemia  with  petechial  eruption. 
February  ^4,  1880. — Amputation  of  arm  at  the  German  Hospital.  Patient  died  two 
hours  after  ablation. 

Case  V. — Catharine  Argast,  aged  fifty-four.  Senile  gangrene  of  fore  part  of  foot 
Septe7nber  18,  1882. — Syme's  amputation  at  the  German  Hospital.  Marastic  thrombo- 
sis of  the  femoral  vein.     Died,  October  23d.  of  marasn)us. 

The  author's  total  rate  of  mortality  wotild  be  11 'GS  per  cent. 

Excluding  the  hopeless  and  moribund  cases  Nos.  1,  3,  and  4,  the  death- 
rate  will  be  reduced  to  4*65  per  cent. 

Not  one  of  the  patients  died  of  acute  septicEemia  or  pyaemia  clearly 
chargeable  to  the  operation.  Case  No.  2  died  of  tuberculosis  ;  case  No.  5 
(senile  gangrene),  of  thrombosis  due  to  general  marasm. 

Considering  the  large  proiwrtion  of  amputations  of  the  thigh  (twenty- 
two),  and  the  fact  that  ablation  was  done  twenty  times  for  acute  septic  pro- 
cesses under  a  vital  indication,  during  a  more  or  less  pronounced  state  of 
general  sepsis,  the  final  results  may  be  favorably  compared  with  those 
achieved  without  antiseptics. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


01 


To  further  a  better  understanding  of  the  methods  employed  for  the 
maintenance  of  the  aseptic  condition  during  amputation,  it  will  be  neces- 
sary to  class  all  cases  requiring  ablation  in  three  groups. 

a.  Cleax  Cases. — The  first  r/roup  consists,  on  the  one  hand,  of  cases 
where  amputation  is  indicated  for  various  reasons,  such  as  deformities, 
tumors,  etc.,  in  which  the  skin  of  the  member  is  unbroken,  and  no  sub- 
cutaneous, acute,  or  chronic  suppuration  is  present  ;  on  the  other  hand,  of 
injuries  requiring  amputation,  that  come  under  treatment  immediately 
after  the  accident. 

These  are  called  clean  cases.  They  require  the  ordinary  aseptic  precau- 
tions, such  as  shaving,  thorough  scrubbing,  and  disinfection  of  the  field  of 
operation,  and  a  careful  protection  of  the  hands  and  instruments  of  the  sur- 
geons from  contact  with  non-disinfected  parts  of  the  patient's  body.  This 
is  best  accomplished  by  wrapping  the  whole  limb,  excepting  the  field  of 
oj^eration,  into  a  swathing  of  disinfected  towels,  which  should  be  fixed  in 
position  by  safety-pins  or  a  few  turns  of  a  roller-bandage.     The  patient's 

feet  and  hands,  disirifec- 
tion  of  which  is  difficult 
at  best,  should  never  re- 
main unnecessarily  ex- 
posed in  amputations  of 
the  upper  or  lower  ex- 

'^^^^^^^^^^^^^*^^^^^^™^*^^  tion  is  to  be  done  near, 

's^  \  \  ^^^^^^^B'^^«^  ^'^''^^^KIB^W  ■  I     01'  ^^  ^^^^  hand  or  foot, 


^^^  these  must  be.  if  time  permit. 

"^'^i-Stl^r^u!     ^^^^j^^\        subjected  to  a  careful  prelim- 
tation  ot  thigh.  MB^  ^^T^^^  ■  \        inary  proccss  of  cleansing.     It 

consists  of  a  prolonged  bath 
of  warm  soap-water,  and  sub- 
sequent packing  in  comj)resses  moistened  with  a  two-per-cent  carbolic  solu- 
tion, and  an  external  wrapping  of  rubber  tissue  to  prevent  evaporation. 
Large  masses  of  epidermis  will  be  soaked  off  in  this  manner,  and  can  be 
removed  by  gentle  friction  with  a  brush  or  flannel  rag  in  soap-water.  This 
process  must  be  rejDeated  until  the  skin  is  perfectly  clean,  and  does  not  shed 
epidermis.      The  part  to  be  operated  on  is  kept  wraj^ped  in  a  carbolized 

towel  until  nnfesthesia  is  well  under  wav,  and  the  operation  is  about  to  begin. 
10 


62 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Esmarcli's  constrictor  being  applied,  and  the  patient's  body  protected 
by  rubber  sheets,  these  and  the  parts  of  the  limb  not  needing  special  dis- 
infection are  covered  with  disinfected  moist  towels.  The  parts  of  the  assist- 
ants are  distributed,  aud  every  one  takes  his  place.  Now  the  surgeon 
unwraps  the  field  of  op- 
eration, and,  having  once 
more  rubbed  it  off  with 
corrosive-sublimate  lotion, 
begins  to  operate. 

Frequent  irrigation  of 
the  wound  and  especially 
rinsing  of  the  hands  of 
operator     and     assistants 


Fig.  48. — Section  of  femur.     Irrigator  playing 
from  the  left. 


should  not  be  neglected  until  the  dress- 
ings are  finished  and  the  patient  is  ready  for  bed.     The  other  precautionary 
detail  mentioned  in  a  previous  chapter  should  also  be  carefully  adhered  to. 

With  the  exception  of  the  saw,  most  instruments  required  for  amputa- 
tion are  easy  to  clean.  The  saw  is  a  frequent  medium  of  pyogenic  in- 
fection. 

Case. — Arnold  Bitter,  mechanic,  aged  thirty-four,  was  amputated  at  the  knee- 
joint  eighteen  years  ago  for  a  compound  fracture  of  the  leg.  On  account  of  insufiicient 
covering,  a  large  adherent  cicatrix  occupied  the  under  and  posterior  side  of  the  condyles, 
which  were  constantly  ulcerated.  Ee-amputation  of  the  thigh  ahove  the  condyles, 
January  8,  1887,  at  the  German  Hospital.  Drainage  and  suture.  Fever  developed 
on  the  second  day,  rising  to  103°  Fahr.  on  the  third,  wherefore  the  house-surgeon  re- 
moved the  dressings,  but  found  nothing  to  explain  the  pain  and  fever.  On  the  fifth 
day  the  author  inspected  the  stump,  and  found  firm  union  of  the  flaps  between  each 
other  and  to  the  sawn  surface  of  the  bone,  the  drainage-tubes  still  filled  with  fresh, 
sweet  clots,  but  the  extremity  of  the  stump  decidedly  club-shaped  and  oedematous,  the 
oedema  being  of  the  deep-going,  firm  variety,  characteristic  of  acute  osteomyelitis. 
The  stump  was  nowhere  painful  on  pressure,  except  at  a  point  corresponding  to  the 
ripper  margin  of  tlie  sawn  surface  of  the  bone.  In  a  few  days  pus  began  to  exude 
from  the  drainage-tube  placed  at  the  time  of  the  operation  through  a  counter-incision 
into  the  quadricipital  bursa,  and  the  patient's  fever  subsided.  Feb.  9th. — The  upper 
margin  of  the  sawn  surface  was  exposed  and  a  narrow,  sharp  edge  of  necrosed  bone 
was  detected.  This  was  chiseled  away  until  healthy  bone  presented  ;  fistula  scraped, 
wound  sutured.     Primary  union  ;  patient  cured,  March  5th. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  63 

Ap])arcntly  some  filtli  had  been  detached  from  the  teeth  of  the  saw  when 
it  was  drawn  across  the  bone  the  first  few  times,  and  became  lodged  near  the 
upper  margin  of  the  bone  section,  causing  there  a  circumscribed  acute 
osteomyelitis,  ending  in  necrosis. 

XoTE. — The  proper  way  to  cleanse  a  saw-blade  is  to  scrub  it  thoroughly  for  five  minutes  in 
hot  water  with  soap  and  a  stiff  brush,  held  across  the  blade,  then  to  immerse  it  in  carbolic 
lotion  until  used.  It  is  best  to  do  this  as  the  last  thing  before  the  operation.  Wiping  with  a 
towel  should  he  avoided,  as  a  number  of  linen  fibers  are  detached  thereby  and  remain  adherent 
to  the  teeth  of  the  saw. 

1).  Mildly  Septic  Cases. — The  second  group  contains  cases  character- 
ized hij  clironic  suppuration,  due  to  tuberculosis  of  joints  or  bones,  or  to 
ulcerative  processes  of  various  kinds  requiring  amputation.  Infection  of 
the  amputation  wound  through  contact  with  hands  or  apparatus  that  have 
touched  the  ulcers  or  fistulas,  or  through  escaping  secretions,  occurs  very 
easily  in  these  cases,  and  special  precautions  have  to  be  employed  to  avoid  it. 

A  careful  examination  of  the  affected  parts  should  be  made  several  days 
or  a  week  before  the  time  appointed  for  the  amputation.  Abscesses  should 
he  incised  and  drained,  retentions  removed  by  counter-incision,  and  the 
amount  of  secretion  reduced  by  all  known  means,  as,  for  instance,  frequent 
irrigation  and  change  of  dressings. 

The  field  -of  operation  should  be  prepared  as  indicated  for  the  first 
group.  Immediately  preceding  the  operation  the  suppurating  focus  or 
nicer  should  be  irrigated  and  dressed  in  bed,  and  over  the  usual  dressing  a 
piece  of  rubber  tissue  should  be  tightly  bandaged  so  as  to  overlap  it  on  all 
sides,  the  margin  of  the  gutta-percha  adhering  to  the  skin. 

The  patient  being  anaesthetized,  Esmarch's  constrictor  is  applied,  and  the 
rubbers  are  arranged  in  the  proper  manner  to  shield  the  patient's  body  from 
drenching  with  the  irrigating  fluid.  After  this  the  whole  surface  of  the 
limb,  with  the  exception  of  the  field  of  operation,  is  wrapped  in  clean 
towels,  the  carbolized  towel  covering  the  site  of  the  operation  is  removed, 
this  and  all  hands  are  finally  disinfected,  the  irrigator  is  started,  and  the 
amputation  should  commence. 

It  is  not  very  difficult  in  these  cases  to  exclude  suppuration  and  to  secure 
primary  union  by  the  exercise  of  a  moderate  amount  of  care  and  by  intelli- 
gent attention  to  important  details. 

Should  infection  occur  on  account  of  faulty  management  or  the  in- 
herent difficulty  of  the  case,  the  inevitable  suppuration  will  be  mostly  of  a 
benign  character,  and  well-nourished  and  well-coapted  portions  of  the  wound 
may  even  heal  by  primary  union. 

WJiere  amputation  lias  to  he  done  through  ulcerating  or  suppurating 
parts  of  a  limh,  the  surgeon  has  a  still  more  difficult  problem  to  solve.  But 
even  in  some  of  these  cases  primary  union  can  be  achieved.  Before  com- 
mencing the  operation,  the  skin  surrounding  the  ulcer  or  sinus  must  be 
thoroughly  scrubbed  with  brush,  soap,  and  water,  then  the  ulcer  or  sinus  is 
repeatedly  washed  or  injected  with  an  eight-per-cent  solution  of  chloride 
of  zinc,  and  the  granulations  are  thoroughly  scraped  off   with  the  sharp 


64 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


spoon.  Indurated  or  illy  nourished  tissues  are  removed,  and  all  debris  is 
washed  away  with  the  irrigating  stream  of  mercurial  lotion.  After  this  the 
ani]ratation  is  done  as  usual,  good  care  being  taken  to  provide  for  ample 
drainage. 

.  c.  Septic  Cases  of  Greater  Intensity. — To  the  third  group  belong 
all  eases  in  which  an  acute  progredient  septic  process  of  spontaneous  or 
traumatic  oridn  necessitates  ablation  of   the  affected   limb  under  a  vital 


Fu..  49. — Secui'in,tj  of  visible  ves- 
sels bj'  artery  forceps. 

indication.  Profusely  sup- 
j)urating  compound  fract- 
ures, rapidly  progressive 
phlegmons  of  the  hand 
and  arm,  cases  of  embolic 
or  other  forms  of  sponta- 
neous gangrene,  compose  this  class,  in  which  the  surgeon  has  to  contend 
not  only  with  the  local  trouble,  but  also  frequently  with  a  deep  and  dan- 
gerous general  intoxication  of  the  system,  due  to  the  massive  absorption 
of  ptomaines  and  bacteria. 

In  many  of  these  cases  the  processes  determining  phlegmonous  destruc- 
tion have  progressed  beyond  the  highest  limit  of  amputation,  and  securing 
of  an  aseptic  state  of  the  wound  is  impossible.  No  amount  of  irrigation 
will  here  do  any  good,  and  the  surgeon,   having  removed  most  of  what  is  a 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


65 


source  of  furtlier  infection,  has  to  trust  to  good  luck  unci  the  power  of 
resistance  of  his  patient,  aided  by  ample  stimulation  and  other  restorative 
measures.     In  these  cases  the  o\)Qn  after-treatment  is  in  order. 

But,  even  in  those  instances  where  amputation  can  yet  be  done  in 
healthy  tissues,  preservation  of  an  aseptic  state  is  an  extremely  difiBcult 
matter  on  account  of  several  reasons.  First  of  all,  we  havejjrofuse  secretion 
of  pus  or  ichor,  containing  an  extremely  virulent  culture  of  micro-organisms, 
a  few  individuals  of  which  are  sufficient  to  start  up  another  phlegmon. 
Nobody  who  has  not  tried  it  can  conceive  the  difficulty  of  keeping  free 
from  contamination  in  such  cases.     Another  difficulty  lies  in  the  limits  to 

our  choice  of  the 


place 
tion. 


Fk;.  50. — Compression  of  cut  surface  by 
sponges  placed  over  the  folded  flaps. 
Eemoval  of  constricting  band. 


of  amputa- 
When  we 
can  go  high  up, 
far  out  of  the 
reach  of  the  infec- 
tion, we  should  al- 
ways do  it  without 
regard  to  so-called 
conservative  con- 
siderations. What 
is  first  to  he  con- 
served here  is  the 
life  of  the  patient, 
and  before  this 
view  all  objections 
ought  to  vanish. 

But,  when  the 
process  has  extend- 
ed up  beyond  the 
knee  or  the  elbow, 
how  keep  free  from 
True,  the  section 
tissues  ;    but, 
even  with  the  greatest  care,  contact-in- 
fection is  almost  unavoidable. 

The  measures  to  be  employed  in  these 
cases  are  similar  to  those  detailed  for  the 
second  group,  only  with  this  difference : 
that  attention  to  every  step  of  the  prepa- 
ration should  be  more  rigid ;  that,  if  pos- 
sible, the  filthy  part  of  the  preparation 


contamination  then  ? 
may  go    through  healthy 


should  be  done  by  a  separate  person  or 
persons ;  and,  finally,  that  the  judicious  use  of  our  strongest  antiseptics  for 
irrigation  (1  :  500  to  1  :  1000  of  corrosive  sublimate)  is  justified.  The  lotion 
used  for  rinsing  the  hands  must  be  repeatedly  changed,  and  everything  that 


66 


EULES  OF  ASEPTIC  x^ND  ANTISEPTIC  SURGERY. 


has  come  in  mediate  or  immediate  contact  with  the  focus  of  infection  must 
be  rigidly  rejected. 

Amputation  wounds  belonging  to  this  group  should  not  be  sutured,  but 
require  loose  packing  and  moist  dressings  (open  treatment). 

Our  first  and  second  groups  coincide  with  "primary^''  and  "secondary," 
the  third  with  ''  intermediate^"  amputations  of  the  old  nomenclaturCo 

2.  Hsemorrliage. — Esmarch's  apparatus  and  the  animal  ligature  have  un- 
doubtedly had  a  great  share  in  bettering  the  statistics  of  major  amputation. 

a.  Artificial  Atst.^mia. — The  most  important  and  really  blood-saving 
part  of  Esmarch's  apparatus  is  performed  by  the  constricting  band,  used 
instead  of  a  tourniquet.  The  theoretical  advantages  of  the  use  of  the  elastic 
roller-bandage,  employed  for  evacuating  the  vessels  of  the  limb,  are  offset  by 
some  serious  drawbacks.  It  is  an  undeniable  fact  that  the  aerostatic  press- 
ure will  effectually  prevent  the  escape  of  considerable  quantities  of  blood 
from  a  limb,  the  circulation  of  which  has  been  suppressed  by  central  con- 
striction. Therefore,  the  exjDuIsion  of  all  the  blood  contained  in  a  limb  is 
not  an  absolute  requirement  of  blood-saving  in  non -mutilating  operations, 
as,  for  instance,  joint  exsections. 

In  amputations  the  blood  contained  in  the  removed  limb  is  an  absolute 
loss,  but  its  quantity  can  be  effectually  limited  to  a  very  small  amount 


Fir;9.  51,  52. — Esmarch's  artery  forceps. 


Fig.  53. — TIalin's  artery  forceps. 


Fig.  54. — Showing 
the  difference  be- 
tween a,  a  good, 
and  6,  a  wortli- 
less,  artery  for- 
ceps. On  com- 
pression, points 
of  a  remain  in 
contact :  those  of 
b  gap. 


by  i)revious  vertical  elevation  of  the  limb.  And  this  loss  is  abundantly 
repaid  by  the  agreeable  assurance,  that  no  septic  material  or  infectious  cell- 
elements,  detached  from  a  malignant  new-growth,  are  thrown  into  the  gen- 
eral circulation  with  the  blood  and  lymph  which  is  expelled  from  the  dis- 
eased limb  by  the  elastic  roller-bandage. 

The  retention  of  a  certain  quantity  of  blood  in  the  vessels  of  the  stump 
affords  additional  advantages  of  no  mean  value.  By  pressure  upon  the 
stump,  the  smaller  and  smallest  arteries  and  veins  each  will  pour  out  a 
minute  quantity  of  blood,  which  will  greatly  aid  the  surgeon  in  finding  and 


SPECIAL  APPLICATION   OF  THE   ASEPTIC  METHOD. 


67 


Fig.  55. — Manner  of  tying 
vessel .     ( Esmarch . ) 


securing  them  before  the  removiil  of  the  constrictor.  Thus  all  considerable 
ostia  can  be  occluded,  so  that,  on  detaching  the  rubber  band,  no  spurting 
vessels  will  be  observed,  and  the  capillary  oozing  will  easily  be  controlled  by 
compression  of  the  wound,  aided  by  digital  pressure 
exerted  upon  the  main  artery  of  the  limb.  Com- 
pression should  not  be  done  by  packing  the  wound 
full  of  sponges,  and  folding  the  skin-flaps  over  these. 
True  that  their  elastic  pressure  will  check  haemor- 
rhage. But,  on  the  other  side,  most  of  the  small 
thrombi  occluding  the  vessels,  that  are  continuous 
with  the  clot  occupying  the  outer  meshes  of  the 
sponge,  are  torn  away  when  the  latter  is  removed, 
and  renewed  oozing  results.  The  same  objection 
must  be  raised  against  vigorous  sjoonging  of  the 
wound-surface.  Even  after  oozing  has  stopped 
completely,  frequent  sponging  is  apt  to  renew  it,  and  thus  to  prolong  the 
time  required  for  stanching  the  haemorrhage. 

A  better  way  of  employing  compression  is  to  fold  the  flaps  over  the  wound, 
and  then  to  arrange  the  sponges  outside  of  them.  This  will  insure  the  good 
effect  of  compression  without  the  disadvantage  mentioned  above  (Fig.  50). 

As  soon  as  all  visible  vessels  have  been  secured,  the  wound  is  compressed, 
and  the  constrictor  is  removed  while  the  limb  is  held  vertically.  The  assist- 
ant who  removed  the  constricting  band  applies  digital  compression  to  the 
main  artery.  Immediately  after  removing  the  rubber  band,  the  skin  of 
the  parts  that  had  been  subjected  to  artificial  anaemia  is  seen  to  flush  up, 
and  to  remain  vividly  red  for  from  five  to  ten  minutes.  This  is  the  period 
of  excessive  hypersemia,  due  to  paresis  of  the  vasomotor  nerves.  Hyperaemia 
is  all  the  more  lasting  and  intense,  the  longer  and  the  tighter  was  the  con- 
striction. Attention  should  be  devoted  by  the  surgeon  to  learn  the  exact 
amount  of  tension  of  the  rubber  required  to  just  stop, arterial  circulation. 

The  band  should  never  be  applied  before  the  patient  is  relaxed,  and  it 
should  not  remain  on  longer  than  absolutely  necessary. 

Note. — The  rubber  constrictor  exerts  an  enormous  amount  of  constant  and  undiminishing 
pressure,  hence  it  must  be  used  with  discretion.  Applying  it  to  the  thigh  held  in  flexion  may 
lead  to  rupture  of  all  flexors  if  the  limb  is  straightened  out  afterward. 

For  a  number  of  years,  the  author  has  discarded  all  specially  made 
bands  and  apparatus  recommended  by  authors  and  sold  by  dealers  for  the 
production  of  artificial  anaemia. 

A  piece  of  pure  gum-elastic  tubing,  of  the  tliicTcness  of  a  mcw?8  index- 
finger  or  thumb,  and  of  the  length  of  one  and  a  quarter  yard,  is  all  that  is 
necessary.  Its  application  is  illustrated  in  Fig.  56.  The  limb  being  held 
vertically  for  a  few  minutes,  the  elastic  tube  is  j)ut  on  the  stretch,  and  thus 
coiled  about  the  limb  once  or  twice,  its  tension  and  the  number  of  turns 
being  determined  by  the  relative  thickness  of  the  limb,  the  muscularity, 
and  amount  of  adipose  tissue  underlying  the  skin.     To  estimate  the  tension 


e>s 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


required,  the  feel  of  the  radial  and  dorsalis  pedis  arteries  may  serve  respect- 
ively.    As  soon  as  their  pulsation  disappears,  the  constriction  is  sufficient. 

When  the  required 
amount  of  constriction 
is  secured,  the  ends  of 
the  tube  are  crossed, 
a  short  piece  of  cord 
or  muslin  bandage  is 
passed  under  the  cross- 
ing, and  is  firmly  tied 
in  a  slip-knot.  The 
ends  of  the  tube  being 
released,  the  rubber 
crowds  up  against  the 
cord,  and  can  not  slip. 
(Fig.  57.) 

This  mode  of  con- 
striction is  very  ener- 
getic, and  deserves  the 
preference  for  very 
large  and  muscular  ex- 
tremities. 

Atiother  practical 
and  more  gentle  tvay 
of  applying  elastic  constriction  is  by  means  of  an  ordinary  pure  gum  roller 
or  Martin'' s  elastic  bandage.  It  is  especially  suited  for  emaciated  limbs  and 
for  operations  on  wo- 
men of  delicate  frame, 
and  children. 

The  manner  of  ap- 
plying Martin's  band- 
age is  well  illustrated 
in  the  accompanying 
cuts.  As  many  turns 
of  the  bandage  are 
superimposed  tightly 
around  the  limb  as 
necessary.  The  last 
turn  is  grasped  in 
the  left  hand,  and  is 
pulled  away  forcibly 
from  the  limb,  form- 
ing a  bight,  into  which 
is  thrust  the  remain- 
der of  the  roller.  As  soon  as  the  left  hand  releases  the  loop,  it  tightens 
about  the  roller,  and  holds  it  in  place  firmly  and  securely.     (Fig.  58.) 


oU. — Mauner  of  applying  elastic  constrictor  (rubber  tube) 
for  the  production  of  artificial  ansemia. 


Fio.  57. — Elastic  constrictor  in  situ. 


SPECIAL  APPLICATION   OF  THE   ASEPTIC   METHOD. 


69 


/"' 


b.  Ligatures  and  Final  IliEMOSTASis. — The  visible  lumina  of  all  cut 
vesselt^ — veins  and  arteries — are  tied  with  catgut,  which  is  in  every  way  pref- 
erable to  silk.  The  objections  raised  against  the  new  material  have  been 
entirely  disproved  by  experience.  The  author  never  saw  one  case  of  sec- 
ondary haemorrhage  from  a  vessel  tied  with  catgut ;  and  knows  of  two  cases 
only,  quoted  on  pages  5  and  56  respectively,  where  catgut  ligatures  slipped 
or  gave  way.  In  both,  very  brittle  catgut  was  used,  and  the  knot  was  not 
sufficiently  tightened  on  account  of  the  fear  of  breakage.  Therefore  it  may 
be  said  that  improper 
material  was  improperly 
applied  in  both  of  these 
instances. 

In  tying  larger  ves- 
sels it  is  very  necessary 
to  grasp  and  withdraw 
them  from  their  sheaths 
for  inspection. 

Arteines  will  some- 
times be  laterally  nicked 
just  a  little  above  the 
transverse  section,  and 
the  ligature  must  be  ap- 
plied above  the  lateral 
opening. 

Large  veins  must  be 
also  well  inspected,  as 
it  may  happen  that  the 

lumen  of  a  hastily  tied  vein  may  be  only  partially  occluded  by  the  ligature. 
An  ordinary  artery  forceps  can  not  grasp  at  once  the  entire  circumference 
of  a  principal  vein,  and  the  author  has  repeatedly  seen  only  one  half  of  the 
vein  deligated  in  the  shape  of  a  dog's  ear,  the  remainder  of  the  vein  con- 


FiG.  58. 


-a.  Applying  of  Martin's  bandage  as  a  constrictor. 
0.  Martin's  bandage  in  situ. 


Fig.  59. — The  wrong  way  of  detaching  the  skin-flap.    The  knife  should  be  held  vertically.   (Esmarch.) 


tinning  to  bleed  in  spite  of  the  ligature.     The  best  way  to  secure  the  entire 
lumen  of  a  large  vein  is  to  grasp  and  withdraw  it  with  one  or  two  forceps 
11 


YO 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  60. — Liston's  bone  forceps 


The  ligature  must  not  be  tightened  too  much 


imtil  its  whole  circumference  is  clearly  visible,  and  then  to  twist  it  around 

its  own  axis,  when  it  will  be  seen  to  form  a  neck  wliicli  can  be  easily  tied. 
Atheromatosis  of  arteries  is  no  valid  objection  to  the  application  of  the 

catgut  ligature. 

The  grasping  of 

vessels    affected 

by  it  is  difficult 

on    account    of 

their  liability  to 

slip  before,  and 

break  after,  be- 
ing caught  by  the  forceps 

on  an  atheromatous  vessel,  or  it  may  cut  through  it. 

Vessels  imbedded  in  sclerosed  tissues  must  be  secured  by  a  circular  stitch. 
After  the  removal  of  the  elastic  constrictor,  local  compression  of  the 

wound  is  kept  up  until  the  marked  hypergemia  of  the  limb  begins  to  wane. 

Then,  an  assistant  compressing  the  main  artery,  the  wound  is  exposed.    The 

glazing  of  clotted  blood  is  re- 
moved by  irrigation  and  gentle 
friction  with  the  tips  of  the 
fingers,  and  the  assistant  is  di- 
rected to  release  the  compressed 
main  artery.  Then  any  addition- 
al vessels  seen  sj)urting  should 
be  secured.  The  hypergemia  of 
the  limb  will  have  ceased  by 
this  time,  and  with  it  the  ooz- 
ing. 

Note. — Should  a  larger  nutrient  ar- 
tery be  divided  at  the  time  of  the  sec- 
tion of  the  bone,  its  bleeding  can  be 
readily  stopped  by  the  insertion  of  a 
short  piece  of  stout  catgut  into  the 
spurting  orifice,  where  it  can  be  left  be- 
hind without  any  harm.  The  employ- 
ment of  wax  for  the  same  purpose  is 
unsafe,  unless  the  material  is  first  ster- 
ilized by  boiling. 

The     statement     that     Es- 
draiued.  march's  apparatus  is  not  blood- 

saving,  but,  on  the  contrary, 
cau.ses  undue  haemorrhage,  is  misleading.  It  may  be  positively  said  that 
skillful  management  of  the  application  of  Esmarch's  constrictor  will  enable 
the  surgeon  to  perform  major  operations  with  an  astonishingly  small  amount 
of  hgemorrhage,  and  tliat  loss  of  much  blood  after  the  removal  of  the  rubber 
band  is  due  to  faulty  manipulation. 


Fig.  CI.  — Aiiipiitati"! 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


71 


3.   Securing  of  a  Good  Stump. — In  circular  ampututions,  as  well  as  in 
flap  operatiourf,  an  important  ot)ject  should  be  to  gain  abundant  covering, 
and  to  bring  about  easy  and  natural  apposition  of  the  wound-surfaces  with- 
out   much    external 
pressure. 

In  performing  cir- 
cular amputation,  the 
assistant  holding  the 
mesial  part  of  the 
limb  can  greatly  in- 
fluence the  shape  of 
the  stump.  As  it  is 
desirable  to  produce 
a  wound  of  the  shape 
of  a  hollow  cone, 
multijDle  circular  sec- 
tions of  not  too  great 
dejDtli  are  commend- 
able, while  the  assist- 
ant successively  re- 
tracts each  layer  divided  by  the  amputating  knife  until  the  periosteum  is 
cut  through  and  pushed  well  back.  The  soft  parts  are  inclosed  in  a  two- 
or  three-tailed  compress  of  sublimated  gauze,  and  the  bone  or  bones  are 
sawed  off,  care  being  taken  on  the  leg  and  forearm  to  complete  the  sec- 
tion of  both  bones  simul- 
taneously. After  this  the 
sharp  edges  of  the  bone 
are  clipped  off  with  bone- 
cutting  forceps,  and  the 
vessels  are  attended  to. 

Musculo-cutaneous  flaps 
make  a  very  good  covering 


Fig.  62. — Amputation  wound  of  leg,  sutured  and  drained.     Keten- 
tive  button  sutures. 


Fig.  63. 
Dressing  of  amputation 
wound  of  the  thigh. 


to  most  stumps,  and  can  be  very  easily  adapted.     As  soon  as  the  haemor- 
rhage is  perfectly  under  control,  suture  of  the  wound  can  be  commenced. 


T2 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  64. — Dressing  of  amputation  wound  of 
the  leg. 


The  author  is  using  exchisively  the  interrupted  suture,  for  reasons  elsewhere 
mentioned. 

If  the  case  was  unimpeachably  aseptic,  and  no  suppuration  is  expected, 
one  medium-sized  drainage-tube  will  suffice  to  carry  away  the  first  secre- 
tions.    Otherwise  abundant  ways  of  egress  must 
be  provided  in  the  shape  of  several  properly  dis- 
tributed tubes.    The  protruding  end  of  each  tube 
is  transfixed  with  a  safety-pin,  and  cut  off  on  a 
level  with  the  skin.    An  ample  dry  dressing,  con- 
sisting of  a  few  layers  of  iodoformed  and  a  gen- 
erous  mass   of    sublimated   gauze    is 
snugly  bandaged  to  the  stump,  so  as 
to  reach  at  least  twelve  inches  above 
the  line  of  section. 

If  proper  care  was  devoted  to  the 
stanching  of  the  hgemorrhage,  no  great 
pressure  will  be  required  to  check  the 
oozing,  which  is,  anyway,  moderate 
after  the  use  of  corrosive  sublimate 
for  irrigation. 

The  idea  of  bringing  about  close 
apposition  of  the  wound-surfaces  by 
energetic  pressure  is  not  to  be  culti- 
vated, as  it  will  lead  to  frequent  marginal  necrosis  of  the  flaps,  frustrating 
complete  j)rimary  union.  Surface  apposition  should  rather  be  accomplished 
by  a  pro]3er  fashioning  of  the  wound  and  flaps, 
and  the  sutures  should  exert  no  traction  what- 
evei",  but  should  merely  secure  contact  of  the 
cutaneous  edges. 

For  securing  contact  of  the  deeper  portions  of 
an  amputation  wound,  Lister's  lead-plate,  or  but- 
ton, sutures  are  very  advantageous.     (Fig.  63.) 

Note. — In  former  times,  when  car- 
bolic lotions  were  employed  for  irriga- 
tion, oozing  used  to  be  quite  free,  and 
necessitated  the  use  of  a  good  deal  of 
pressure,  which  was  somewhat  tempered 
by  the  interposition  of  thick  layers  of 
borated  cotton  between  the  dressing 
proper  and  the  outer  bandage.  Flap 
necroses  were  then  much  more  com- 
mon than  nowadays. 

The  sole  office  of  the  dress- 
ings is  to  lightly  support  the 
wound,  and  to  absorb  and  ren- 

T        .  ,,  ,.  Fig.  ()5.  - Ainiiutatioii  wound  <il' tin;  tliifi'li  fourteen 

der  innocuous  the  secretions.  days  afUT  tlic  oiiciation.     C:i:<i'  ,,f  .Mrs.    Walthcr. 


SPECIAL   APPLICATION  OF  THE  ASEPTIC   METHOD. 


73 


The  author's  custom  is  to  make  the  first  change  of  dressings  about  a 
fortnight  after  tlie  operation,  when  tlie  drainage-tubes  can  be  withdrawn. 
Another  lighter  aseptic  dressing  is  then  applied,  and  remains  undisturbed 
for  a  week.  By  the  end  of  this  time  the  drainage-tracks  will  have  either 
healed  completely,  or  their  place  will  be  marked  by  a  small  patch  of  granu- 
lations, requiring  merely  a  borated-salve  or  simple  adhesive-plaster  covering. 

This  refers  to  correct  cases  only.  Should  septic  fever  develop  or  mar- 
ginal gangrene  be  noted,  frequent  moist  dressings  are  in  order,  and  the  rules 
appropriate  for  the  treatment  of  suppurating  wounds  obtain  precedence. 

Case  :  Illustrating  a  Correct  Course  of  Healing.— Mr?,.  Panliiie  Walther,  seam- 
stress, aged  fit'ty-one.  Far-gone  tuberculous  destruction  of  knee-joint  with  fistula,  the 
latter  the  result  oi*  a  previous  exploratory  incision.  Feh.  IJ^th. — Amputation  of  thigh 
in  middle  third.  Aseptic  fever,  with  rise  of  temperature  to  103°  Fahr.,  on  the  two  days 
following  the  operation.  Feb.  18t?i. — Temperature,  99°  Fahr.  March  1st. — First 
change  of  dressings;  drainage-tubes  removed;  wound  redressed.  March  7th. — Wound 
completely  healed,  except  where  one  minute  spot  of  granulations  marks  the  former  site 
of  a  tube.  March  12th. — All  firmly  cicatrized ;  the  stump  can  be  lightly  pounded 
without  pain.     March  17th. — Patient  discharged  cured.     See  Figs.  61  and  65. 


IV.     OPERATIONS    ABOUT    NON-SUPPURATING    JOINTS. 

1.  Puncture  and  Irrigation. — Chronic  hydrops,  or,  as  Volkmann  calls 
it,  catarrhal  synovitis  of  the  knee-joint,  is  often  benefited  or  even  cured 
by  puncture  and  subsequent  irrigation. 

Schede's  rule  of  using  corrosive  sublimate  (1 : 1,000) 
whenever  the  synovial  fluid  is  turbid,  and  carbolic 
lotion  (three  per  cent)  when  it  is  clear,  can  be  com- 
mended as  rational.      In  the  former   case  pyogenic 
elements  cause  the  production  of  a  certain  amount  of 
lycocythes,  and  hence  the  use  of  a  strong  germicide 
like  corrosive  sublimate  is  appropriate. 
Simple  hydrops,  where  there  is  no  ad- 
mixture of  pus-cells,  is  comparable  to 
bursal   hydrops  or   hydrocele,   and   is 
benefited  by  the  ap- 
plication of  an  irri- 
tant  substance   like 
carbolic  acid. 

The  manner  of 
procedure  employed 
by  the  author  is  as 
follows  : 

Two    large  -  cali- 
bered  trocars  are  ren- 
dered aseptic  either 
by  boiling  the  tubes  for  an  hour  in  a  five-per-cent  solution  of  carbolic  acid, 
or  by  heating  them  in  a  large  alcohol  flame  to  incandescence,  after  which 


Fig.  66. — Irrigation  of  knee-joint. 


74  EULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

they  are  dropped  into  carbolic  lotion.  Too  much  care  can  never  be  exer- 
cised in  attending  to  the  proper  disinfection  of  the  trocar-tubes,  as  their 
hollow  shape  renders  their  cleansing  a  difficult  matter  at  best. 

Case. — Thomas  Casey,  hostler,  aged  twenty-three.  Hydrops  of  right  knee-joint 
of  several  years'  standing.  Marcli  llf.^  1887. — Puncture  and  irrigation  with  Thiersch's 
solution  and  carbolic  lotion.  Dorsal  splint.  The  trocars  had  received  a  rather  super- 
ficial attention  by  boiling  of  too  short  duration.  The  following  day  high  fever  appeared 
with  great  distention  of  the  joint.  March  15th. — Aspiration  yielded  pus.  March  16th. 
— Multiple  incision  and  drainage.  The  fever  not  abating,  although  secretion  was  very 
scanty,  the  limb  was  suspended  in  a  wire  cradle,  and  weight  extension  was  applied,  so 
as  to  enable  the  house-surgeon  to  frequently  irrigate  the  joint  without  disturbing  the 
patient's  rest.  In  spite  of  the  most  attentive  treatment,  new  abscesses  developed,  and 
the  patient's  evident  failing  finally  compelled  amputation  of  the  thigh,  which  was  done, 
May  30th,  by  Dr.  F.  Lange.  The  patient  recovered.  Extensive  tuberculosis  of  the  liead 
and  shaft  of  the  tibia  was  ascertained  by  examining  the  specimen. 

After  the  usual  preparation  of  the  patient's  limb,  the  trocars  are  thrust 
into  the  knee-joint  from  opposite  sides,  and  the  synovial  fluid  is  let  out. 

To  remove  flocculse  of  coagulated  fibrin,  Thiersch's  solution  is  first  used 
for  washing  out  the  joint  cavity.  The  reason  for  this  is  the  fact  that  car- 
bolic acid  hardens  the  fibrinous  clots  and  makes  them  tough  and  unfit  to 
pass  the  cannula.  Corrosive  sublimate,  on  the  other  hand,  is  poisonous, 
and  dangerous  quantities  of  it  may  be  absorbed  if  irrigation  be  carried  on 
sufficiently  long  to  free  the  joint  of  all  deposits  of  fibrin. 

Case. — John  Schurz,  mason,  aged  thirty,  chronic  hydrops  of  knee-joint.  April  8, 
1886. — At  the  German  Hospital,  double  puncture  and  rather  prolonged  irrigation  with 
corrosive- sublimate  lotion  (1  : 1,000)  on.  account  of  the  presence  of  large  quantities  of 
fibrinous  deposit.  April  10th.  —Mercurialism  ;  salivation  and  sharp  colic,  lasting  for  five 
days,  with  some  fever,  ending  in  recovery  on  appropriate  treatment.     Hydrops  cured. 

As  soon  as  Thiersch's  fluid  is  seen  to  escape  clear  from 
the  efferent  cannula,  corrosive  sublimate  or  carbolic  lotion 
is  substituted  therefor,  and  the  joint  is  thoroughly  flushed 
with  it.  To  prevent  the  retention  of  a  dangerous  amount 
of  either  of  these  solutions,  the  joint  is  flexed  and  emptied 


-Volknian's  T-splint. 


by  external  pressure.  The  tubes  are  withdrawn,  a  small  patch  of  iodoform 
gauze  is  attached  with  a  strip  of  adhesive  plaster  over  each  puncture-hole, 
and  the  limb  is  jjlaced  on  a  dorsal  splint,     (Fig.  67.) 


SPECIAL   AFFLICATK^N   OF  THE   ASEFTIC   METHOD.  75 

2.  Arthrotomy  for  Chronic  Fibrinous  Hydrops,  for  Vegetations,  Tumors, 
and  Floating-  Bodies  of  the  Knee-joint,  a.  Hydrops  Geni'. — In  cases 
where  a  thick  coating  of  fibrinous  deposit  is  lining  the  entire  cavity  of  the 
knee-joint,  simple  puncture  and  irrigation  will  be  found  impracticable  on 
account  of  the  continuous  clogging  of  the  efferent  cannula.  To  completely 
free  the  joint  of  these  masses,  immediate  incision  must  be  done.  The  in- 
ternal aspect  of  the  knee  presents  the  most  convenient  place  for  this  pro- 
cedure. The  skin  and  fascia  are  successively  incised,  and  all  bleeding  vessels 
are  carefully  tied.  On  being  exposed,  the  bluish  capsule  is  cut  into,  and 
the  incision  is  extended  to  about  an  inch  in  length.  After  this,  irrigation 
by  Thiersch's  solution  is  practiced,  and  the  joint  is  repeatedly  flexed  and 
extended  to  aid  detachment  and  expulsion  of  the  membrane,  which  can  be 
hastened  by  sweeping  the  index-finger  through  all  the  recesses  of  the  joint. 
The  slight  haemorrhage  following  this  manipulation  will  cease  spontane- 
ously, and  the  clots  are  washed  out  by  a  strong  jet  of  irrigating  fluid. 


Fig.  GS.~  Ari'imguuicut  <jf  rubber  .sheets  fur  ojioratiouis  abuut  the  lower  extremity. 

After  the  insertion  of  a  short  piece  of  medium-sized  drainage-tube,  which 
should  reach  just  within  the  cavity  of  the  joint,  the  capsular  incision  is 
closed  by  a  few  interrupted  catgut  sutures. 

The  fascia  and  skin  are  likewise  united,  the  protruding  end  of  the  tube 
is  transfixed  with  a  safety-pin  and  trimmed  off  short,  and  the  joint  receives  a 
final  flushing  with  carbolic  or  mercurial  lotion  according  to  the  indications 
mentioned  in  the  preceding  paragraph. 

After  this  the  wound  is  dressed  and  the  limb  is  fixed  upon  a  dorsal  splint. 

If  the  aseptic  measures  were  sufficient,  no  reaction  whatever  will  follow 
the  operation.  In  cases  where  the  hydropic  fluid  was  limpid,  no  secretion 
of  any  account  will  be  observed,  and  the  tubes  can  be  withdrawn  at  the  first 
change  of  dressings,  which  is  usually  done  on  the  fifth  day  after  the  opera- 
tion. As  soon  as  the  wound  is  in  progress  of  cicatrization,  active  movements 
and  cautious  use  of  the  limb  should  commence,  the  joint  being  protected 
by  a  small  aseptic  dressing,  held  in  place  by  Martin's  elastic  bandage. 

Case  of  John  Sclmrz,  page  Y4,  who  was  discharged  cured  June  29,  1886,  with 
partially  restored  and  constantly  improving  mobility. 

Passive  movements  are  unnecessary  and  very  painful.  Restoration  of 
the  mobilit}''  should  be  hastened  by  cold  or  warm  douching  and  subsequent 


76  RULES   OF   ASEPTIC  AND   ANTISEPTIC   SURGERY. 

massage,  and  its  final  establishment  left  to  the  active  efforts  of  the  patient 
himself. 

Cases  in  which  large  quantities  of  firmly  adherent  membrane  were 
removed  and  some  haemorrhage  followed,  especially  if  the  hydropic  fluid 
was  very  turbid,  will  develop  a  moderate  secretion  of  serous  bland  pus,  that 
may  continue  for  some  time.  Some  fever  will  also  occur,  to  subside  as  soon 
as  the  dressings  are  changed  and  the  joint  is  washed  out  again. 

It  will  commend  itself  to  apply  in  these  cases  a  fenestrated  plaster-of- 
Paris  splint,  and  to  repeat  irrigation  once  or  twice  daily  in  the  beginning, 
diminishing  the  number  of  washings  pari  passu  with  the  disappearance  of 
the  secretion.  As  soon  as  the  discharge  shall  have  become  serous  and 
scanty,  the  tube  can  be  withdrawn  and  the  case  treated  as  above  explained. 

Case. — Fred.  Schecker,  laborer,  aged  twenty-six,  had  been  suffering  for  several 
years  from  a  painless,  massive,  hydropic  distention  of  the  right  knee-joint,  that  could 
not  be  traced  to  a  traumatism.  Considerable  lateral  mobility  was  the  main  cause  of  his 
seeking  relief  at  Mount  Sinai  Hospital.  Dec.  7,  i555.— Double  puncture  and  irriga- 
tion were  done,  but  had  to  be  abandoned  on  account  of  large  masses  of  dense  fibrin. 
Immediate  incision  and  clearing  of  the  joint  were  practiced.  Fever  and  some  secretion 
being  noted,  the  dressings  were  changed  December  10th,  and,  the  limb  being  put  up  in 
a  fenestrated  plaster  splint,  irrigation  with  corrosive  subhmate  was  employed  twice — 
later  on,  once — daily.  Dec.  20th. — Normal  temperature  was  noted.  Feb.  1st. — Irriga- 
tion discontinued  and  splint  removed.  Feh.  20tTi. — Patient  discharged  cured,  with 
increasing  tiexion  (twenty  degrees). 

h.  Vegetations. — The  favorite  seat  of  vegetations  in  the  knee-joint  is 
that  lax  part  of  the  capsule  situated  below  the  inferior  margin  of  the  patella, 
which  is  overlaid  by  a  thick  cushion  of  loose  fat  and  the  ligamentum 
patella  proprium.  They  are  rarely  pedunculated,  their  common  appear- 
ance being  that  of  a  yellowish  or  purple  coxcomb,  and  their  direction  trans- 
verse. The  functional  disturbance  produced  by  them  is  sometimes  very 
slight,  but  occasionally  extremely  severe,  especially  when  it  happens  that 
their  margin  is  caught  and  jammed  in  between  the  articular  surfaces. 
Haemorrhage  with  acute  synovitis  and  an  effusion  may  follow  this  accident. 

The  diagnosis  of  vegetations,  sufficiently  massive  to  cause  functional 
trouble,  is  not  difficult  to  the  careful  examiner.  Frequently  the  patients 
themselves  will  point  out  the  kernel-like  slipping  bodies  of  soft  consistency. 
They  are  easily  distinguished  from  free  floating  bodies  by  the  fact  that  on 
manipulation  they  never  disappear  entirely  from  their  seat  of  predilection, 
to  rea])pear  in  a  distant  part  of  the  joint. 

Topical  treatment  is  generally  powerless  against  this  complaint, 
although  the  constant  use  of  a  Martin's  bandage  may  mitigate  the  trouble 
h»y  confining  somewhat  the  motion  of  the  joint,  and  thereby  diminishing  the 
chances  of  contusion  of  the  growths  by  jamming. 

In  aggravated  forms,  arthrotomy  and  excision  of  the  vegetations  is 
proper.  With  strict  attention  to  the  cautelse  before  mentioned,  the  joint  is 
incised,  and,  the  patella  being  tilted  upward  by  a  sharp  retractor,  the  mass 
is  grasped  with  a  i)airof  mouse-tooth  forceps,  and  is  bodily  excised.     Should 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.  77 

it  extend  across  the  entire  width  of  the  patella,  another  lateral  iiici.sion  will 
have  to  be  made  011  the  opposite  aspect  of  the  knee,  to  enable  the  surgeon 
to  complete  the  excision. 

If  much  hypcra^mia  of  the  growth  be  present,  as  shown  by  its  purplish 
color,  haemorrhage  may  be  rather  free.  In  such  a  contingency  the  raw  sur- 
face should  be  seared  with  the  thermo-cautery. 

Toilet  of  the  joint  cavity  is  followed  by  suture,  and  a  small  drainage- 
tube  is  inserted  to  serve  as  a  safety-valve.  The  subsequent  treatment  coin- 
cides with  that  given  for  simple  hydrops  after  puncture  and  irrigation. 

Case  1. — Miss  Lena  C,  aged  fourteen,  vegetations  occupying  the  internal  inferior 
margin  of  the  patella.  The  patient  had  hequent  attacks  of  sudden,  very  sharp  pain 
in  the  knee,  followed  by  effusion.  Various  plans  of  local  treatment  had  been  era- 
ployed  unsuccessfully  for  about  a  year.  JDec.  5,  1881. — With  the  assistance  of  Dr.  B. 
Scharlau,  the  family  attendant,  incision  of  knee-joint  on  its  inner  aspect  was  done. 
A  series  of  yellow,  smooth  bodies  presenting,  they  were  excised  with  forceps  and 
curved  scissors.  Drainage,  suture,  and  plaster- of-Paris  splint.  Some  fever,  due  to 
constipation,  but  no  inflammation  followed.  Dec.  9th. — A  laxative  being  administered, 
a  copious  stool  was  had,  whereupon  the  temperature  at  once  fell  to,  and  remained  at 
the  normal  standard.  Dec.  12tTi. — The  tube  was  removed.  About  New  Year's  the 
patient  commenced  to  walk  about,  and  shortly  after  was  discharged  cured.  In  the 
spring  of  1886  ci^-cumscribed  swelling  of  the  synovial  membrane  in  the  vicinity  of  the 
cicatrix  was  noted.  It  subsided  upon  the  use  of  an  elastic  bandage,  which  was  ulti- 
mately abandoned.     In  January  of  1887  the  patient  was  stih  perfectly  well. 

Case  2. — Frank  Mann,  clerk,  aged  twenty-five,  well-defined  painful  vegetations 
to  be  felt  near  the  lower  margin  of  the  knee-pan,  on  both  sides.  Duration  of  trouble, 
six  months.  Functional  disturbance  very  marked.  April  8,  1886. — Double  incision 
of  knee-joint  at  the  German  Hospital.  Excision  of  a  deep-red,  transversely  situated, 
coxcomb-like  growth  from  the  lower  rim  of  the  patella.  A  good  deal  of  oozing  neces- 
sitated searing  of  the  denuded  surface  of  the  capsule  with  the  thermo-cautery.  Drain- 
age; pi aster-of -Paris  splint.  Eventless  course  of  healing.  The  tube  was  removed  on 
the  tenth  day.     Patient  discharged  cured,  with  good  motion.  May  20,  1888. 

c.  Floatiistg  Bodies  op  the  Knee- Join"t  : 

Case.— E.  Behrmann,  painter,  aged  thirty-eight.  Large  floating  body  of  the  knee- 
joint,  with  chronic  hydrops.  May  15,  1886. — Arthrotomy  at  the  German  Hospital. 
Previous  to  the  incision  the  floating  body  was  fixed  by  finger-pressure  near  the  hne  of 
section,  but  disappeared  in  the  joint  cavity  when  the  last  stroke  of  the  knife  opened 
the  capsule.  The  author  swept  through  the  joint  with  a  well-rinsed  finger,  and  found 
the  body  in  the  bursa  of  the  quadriceps  muscle.  By  means  of  bimanual  manipulation, 
the  body  was  brought  down  to  the  aperture,  and  was  readily  extracted.  Irrigation 
with  corrosive-sublimate  lotion,  drainage,  suture,  and  fixation  upon  a  dorsal  splint  fol- 
lowed the  extraction.  Normal  course  of  healing.  June  15,  1886. — The  patient  was 
discharged  cured  with  good  function  of  the  knee. 

cl.  SuTUEiisrG  OP  THE  Fractueed  Patella. — Although  not  perfect, 
yet  the  functional  results  achieved  by  the  ordinary  forms  of  treatment  em- 
ployed in  cases  of  transverse  fracture  of  the  patella  are  generally  so  good, 
that  arthrotomy,  for  the  sake  of  wiring  or  otherwise  suturing  the  patellary 
fragments,  is  rarely  if  ever  justified  at  a  time  immediately  following  the 
12 


78  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

injury.  Hamilton  has  shown  tliat  even  a  considerable  degree  of  diastasis 
of  the  fragments  is  not  incompatible  with  a  very  fair  functional  ability  of 
the  limb,  provided  that  the  intervening  ligamentons  baud  be  strong,  the 
action  of  the  quadriceps  vigorous,  and  the  lateral  extensions  of  the  quadri- 
ceps tendon  uninjured. 

It  seems,  then,  rational,  in  cases  of  patellary  fractures,  first  to  employ 
the  usual  methods  of  treatment  by  rest  and  appropriate  bandaging,  and  thus 
to  await  the  result.  It  never  can  be  predicted  with  accuracy,  and  may  turn 
out  to  be  very  satisfactory  after  all. 

Should  the  result  be  unsatisfactory,  either  through  failure  of  union  or 
subsequent  rupture  of  the  new-formed  ligament,  arthrotomy  and  secondary 
suture  may  properly  be  taken  into  consideration. 

On  account  of  the  presence  of  large  quantities  of  blood  and  serum,  found 
shortly  after  the  accident  effused  into  the  joint  and  its  vicinity,  primary 
arthrotomy  for  patellary  fracture  is  a  more  risky  undertaking  than  the  sec- 
ondary operation.  The  slightest  error  in  the  use  of  the  aseptic  apparatus 
may  cause  irreparable  damage,  and  may  cost  the  patient's  limb  or  life. 
EsiDecially  dangerous  are  those  cases  in  which  open  ulcers  or  abrasions,  or 
other  secreting  wound-surfaces  due  to  the  primary  injury,  are  located  near 
the  field  of  operation,  be  they  however  small  or  superficial.  Pyogenic  in- 
fection and  suppuration  of  the  knee-joint  are  here  nigh  to  inevitable. 
Anchylosis  is  the  most  favorable  issue  that  can  be  expected  in  case  of  sup- 
puration ;  very  often,  however,  the  limb  will  have  to  be  sacrificed. 

The  conditions  for  the  successful  performance  of  the  secondary  opera- 
tion are,  as  far  as  the  chance  of  avoiding  suppuration  is  concerned,  infinitely 
better.  The  effusions  due  to  recent  traumatism  are  mostly  absorbed,  the 
parts  have  recovered  their  physiological  equilibrium,  and  faults  of  aseptic 
technique  are  easier  to  avoid  and  not  as  hard  to  remedy  as  in  recent  cases. 

The  circumstance  can  not  be  urged  as  a  serious  drawback,  that  a  few 
weeks  after  the  accident,  the  fracture-planes  are  found  covered  with  new- 
formed  connective  tissue  or  a  cicatrix,  and  that  this  must  be  first  removed 
before  suture  can  be  applied. 

More  difficulty  may  be  encountered  in  overcoming  the  retraction  of  the 
quadriceps.  But  even  such  high  degrees  of  retraction  as  are  occasionally 
observed  in  complete  failure  of  union,  or  met  with  in  old  secondary  rupture, 
representing  a  diastasis  of  several  inches,  can  be  managed  so  as  to  permit 
suture  and  bony  union  of  the  fragments. 

The  mode  of  procedure  is  well  illustrated  by  the  following  history  : 

Case. — Mrs.  Lizzie  P.,  housewife,  aged  twenty-eight,  an  extremely  obese  woman, 
contracted  in  1884  a  transverse  fracture  of  the  left  patella,  which  was  attended  to  by 
her  family  pliysician,  and  was  treated  by  rest  and  bandaging.  It  healed  with  a  seem-' 
ingly  satisfactory  ligamentous  union,  which,  however,  gave  way  a  few  weelis  after 
the  completion  of  the  treatment,  resulting  in  a  wide  gap  between  tiie  fragments.  Meas- 
urement gave  a  hiatus  of  two  and  a  half  inches  in  extension,  five  inches  in  fiexion  at  a 
riglit  angle.  Her  gait  was  rather  uncertain,  causing  many  falls,  one  of  which  produced, 
May  2,  1887,  a  transverse  fracture  of  tlie  right  patella.    This  recent  fracture  was  treated 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.  79 

by  approximation  with  two  broad  strips  of  adhesive  plaster,  bandaged  on  and  hiced, 
the  limb  resting  on  a  T-splict.  May  25th. — Tlie  old  patellary  fracture  was  united  by 
operation  at  the  German  Hospital.  The  limb  having  been  rendered  anaemic  by  con- 
striction, the  joint  was  laid  open  by  a  transverse  incision,  and  the  cicatricial  tissue 
investing  the  fracture-planes  of  the  knee-pan  was  cut  away,  and  the  bone  scraped  free 
from  all  adhering  connective  tissue,  until  the  corresponding  surfaces  of  the  patella 
were  clean  and  smooth.  After  this  four  equidistant  holes  were  drilled  through  each 
fragment,  while  the  bone  under  treatment  was  held  immovably  fixed  by  an  assistant 
in  the  grasp  of  a  lion-jaw  forceps.  The  drilling  of  the  apertures  in  the  upper  fragment 
was  much  easier  than  of  those  in  the  lower  one.  By  the  aid  of  a  flexible  silver  probe, 
a  double  thread  of  thick  catgut  (No.  4)  was  drawn  through  the  corresponding  drill- 
holes, the  ends  of  each  suture  being  temporarily  secured  in  the  grip  of  an  artery  for- 
ceps. The  most  difficult  part  of  the  operation  consisted  in  the  approximation  of  the 
fragments.  The  quadriceps  tendon  was  exposed  by  a  longitudinal  incision  of  six  inches 
in  length,  and,  the  upper  fragment  being  forcibly  drawn  downward  with  bone-forceps, 
a  number  of  alternating  latei'al  notches  were  cut  into  the  muscle  and  tendon,  until  the 
fragment  yielded  to  moderate  traction.  The  first  suture  nearest  the  edge  of  the  patella 
was  tightened — not  tied — by  an  assistant  until  the  fragments  were  brought  in  contact, 
whereupon  the  second  suture  was  firmly  knotted.  After  this  the  fourth  sutur-e  was 
tightened  and  the  third  one  tied ;  finally,  the  two  outermost  sutures  were  attended  to. 
The  ends  of  the  catgut  were  trimmed,  and  three  short  drainage-tubes  were  inserted  in 
the  three  angles  of  the  wound.  During  the  whole  operation  a  stream  of  a  1  :  2,500 
solution  of  corrosive-sublimate  lotion  was  played  on  the  exposed  tissues.  Before  the 
closure  of  the  wound,  it  was  finally  fiushed  with  a  1  :  1,000  mercuric  solution,  and  the 
application  of  a  number  of  external  catgut  stitches  completed  the  process.  The  knee 
was  enveloped  in  an  ample  dry  dressing  and  a  plaster-of-Paris  splint,  enforced  by  a 
few  lateral  strips  of  white-wood  veneering.  Finally,  the  constricting  elastic  band  was 
removed,  and  the  extremity  suspended  in  the  vertical  position,  which  was  abandoned 
twenty-four  hours  after  the  completion  of  the  operation.  June  3d. — Splint  removed; 
dressings  changed ;  drainage-tubes  withdrawn.  June  17th. — Wound  healed  through- 
out. Silicate  splint  applied.  June  20th. — Patient  commenced  to  walk  on  crutches. 
July  2d. — She  was  discharged  cured.  July  13th. — The  union  of  sutured  patella  was 
found  firm,  the  operated  limb  much  more  useful  than  its  mate.  Flexion  could  be  car- 
ried to  a  right  angle.     The  course  of  healing  of  the  case  was  feverless  throughout. 

3.  Arthrotomy  for  Irreducible  or  Habitual  Dislocatioii,  and  for  Deformity 
due  to  Fracture. — Dislocations  that  are  irreducible  from  the  outset,  or  have 
become  so  through  neglect,  can  be  corrected  by  means  of  aseptic  ar- 
throtomy. 

Case  I. — Henry  Kohler,  aged  nine.  Dislocation  of  basal  phalanx  of  thumb  upon 
dorsum  of  metacarpal  bone,  of  six  weeks'  standing.  December  S9,  1879. — Repeated 
unsuccessful  attempts  at  reduction  under  chloroform.  Immediate  arthrotomy.  Dis- 
section of  abnormal  adhesions,  and  excision  of  a  shred  of  interposed  capsular  tissue, 
followed  by  ready  reduction.  Suture  and  catgut 
drainage.  Primary  union.  Jan.  10th. — Patient 
discharged  cured  with  improving  function. 

Case  II. — John  Becker,  aged  twelve.     Fresh 

compound  dislocation  of  terminal  phalanx  of  the 

ring-finger  on  the  dorsum  of  the  middle  phalanx. 
1^       I    /nr>    -,r,r,i       T-ixi  T     •    •  i        T     ^  j_i  FiG-  69.  —  Explaininfic  relation  of  parts 

March  29,  I884.— Ether  was  admmistered  at  the  jn  joi^n  Becker' s'"case  of  phalangeal 

German  Hospital,  and,  after  careful  disinfection  dislocation. 


80 


RULES  OP  ASEPTIC   AND  ANTISEPTIC  SUEGERY. 


Fig.  to. — Arrangement  of  rubber  slieets  tor  operations 
about  the  upper  extremity. 


of  tlie  patieot's  band,  reduction  was  repeatedly  attempted  without  success.  The  small 
transverse  laceration  of  the  integument  of  the  volar  aspect  of  the  finger  did  not  give 
the  least  advantage  as  to  examining  the  interior  relations  of  the  displacement,  hence  a 
lateral  incision  was  made  on  the  radial  side.  It  was  then  ascertained  that  the  tendon 
of  the  flexor  digiti  profundus  was  displaced  upon  the  dorsum  of  the  middle  phalanx,  and 

was  interposed  between  the  ar- 
ticulating surfaces.  An  addi- 
tional lateral  incision  on  the 
opposite  side  of  the  finger  was 
necessary,  and  reduction  could 
only  be  accomplished  after  a 
free  division  of  all  resisting 
bands  of  torn  capsular  ligament, 
caught  between  the  flexor  ten- 
don and  the  articulating  surfaces 
respectively.  Suture  and  catgut 
drainage ;  fixation  of  the  finger 
on  a  small  volar  splint.  April 
Bill. — ^First  change  of  dressings. 
Primary  union.  In  May  the 
function  of  the  injured  joint  be- 
came nearly  normal.  (Fig.  69.) 
Case  III. — -Joseph  Jeretzky,  aged  eight.  Old,  irreducible  dislocation  of  basal  pha- 
hmx  of  index  upon  the  dorsum  of  the  metacarpus.  May  19,  I884. — Lateral  incision. 
Division  of  the  new-formed  cicatricial  bands ;  removal  of  an  interposed  shred  of  the 
capsular  ligament.     Keduction  and  primary  union  with  perfect  restoration  of  function. 

Condylar  fractures  of  the  elhoiv  imtli  posterior  or  lateral  displacement 
of  the  forearm  are  a  common  injury  with  children.  What  with  the  great 
difficulty  of  an  exact  diagno- 
sis in  the  presence  of  a  large 
effusion,  and  the  great  differ- 
ences of  opinion  of  the  au- 
tliors  as  regards  the  proper 
manner  of  treatment,  no  won- 
der that,  after  elbow-fract- 
nres,  cases  of  gun-stock  de- 
formity and  partial  disloca- 
tion with  inability  to  flex  the 
elbow  are  not  at  all  rare. 
Some  of  the  authors  adyise 
putting  up  of  the  fracture  in 
extension,  others  in  flexion ; 
some  recommend  early  pass- 
ive motion  with  frequent  change  of  the  angle  of  the  elbow;  others  condemn 
altogether  early  passive  motion. 

The  author's  conviction  is  that  in  many  instances  exact  reposition  and 
retention  are  utterly  impossible  unless  the  fragment  is  cut  down  upon  and 
sutured  or  nailed  to  its  original  seat.     The  insertions  of  the  muscles  of  the 


i'lG.  71. — Dressintc  for  wounds  of  hand  and  forearm. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


81 


forearm  about  tlie  epicondyles  must  exert  a  great  influence  upon  the  dis- 
placement of  the  fragments,  hence  it  seems  that  flexion  would  be  the  better 
position  to  counteract  the  tendency  to  displacement.  But  all  assertions 
made  to  that  effect,  that,  in  spite  of  the  presence  of  a  large  swelling,  reduc- 


FiG.  72. — Anterior  view  of  gun-stock  deformity  due  to  elbow  fracture. 

tion  can  always  be  accomplished  and.  retention  maintained,  have  appeared 
to  the  author  as  a  hollow  pretense  or  self-deception. 

A  very  guarded  prognosis  in  elbow-fractures  is,  on  the  part  of  the  physi- 
cian, a  sign  of  wisdom  and  discretion. 

Where  very  limited  motion  and  an  unfavorable  position  result  in  spite 

of  careful  treatment,   the  only  means  of 
■i        correction  is  arthrotomy  with  subsequent 
I        partial  or  total  exsection. 


Fig.  73.— Lateral  view  of  Bernhard 
Loebel's  elbow. 


Fig.  74. — Normal  aspect  of  lower  end  of  hume- 
rus. A  A.  Transverse  diameter,  b  b.  Line  of 
fracture.     In  Bernhard  Loebel's  case. 


Case  I. — Bernhard  Loebel,  aged  two,    October  27,  1886,  injured  his  elbow  by  fall- 
ing oif  a  chair.     The  arm  was  put  up  by  a  physician  in  the  flexed  position  in  plaster 


Fig.  75. — Showing  relative  positions  of  frag- 
ments in  Bernhard  Loebel's  cass. 


Fig.  76. — Anterior  view  of 
lower  end  of  humerus  in 
Bernhard  Loebel's  case. 


of  Paris,  and  remained  in  this  dressing  for  a  fortnight.     JDec.  7,  1886. — The  elbow- 
joint  showed  very  marked  gun-stock  deformity.     It  was  held  at  an  angle  of  about 


82 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


one  hundred  and  forty  degrees.  Flexion  could  be  carried  to  about  one  hundred  and 
ten  degrees;  extension  not  beyond  the  angle  first  mentioned.  The  forearm  was  dis- 
placed inward  and  backwai'd,  and  the  tendon  of  the  triceps  described  a  well-pro- 
nounced concave  line.  An  abnormal  mass  of  bone  could  be  felt  in  the  bend  of  the 
elbow  externally,  behind  and  below  which  the  head  of  the  radius  could  be  made  out 
with  some  difficulty.  A  posterior  incision  midway  between  the  abnormal  mass  of 
bone  and  the  olecranon  opened  the  joint,  and  the  periosteum  was  raised  by  means  of 
the  knife  and  elevator  on  both  sides  of  the  incision  until  the  lower  end  of  the  humerus 
could  be  turned  out  for  inspection.  It  was  found  that  the  deformed  callus  consisted  of 
the  external  epicondyle,  capitellum,  and  a  small  portion  of  the  trochlea  that  had  been 
broken  otf  obliquely,  and  was  tilted  and  pulled  forward  by  the  action  of  the  flexors  so 
as  to  present  its  articular  aspect  forward,  part  of  the  fractured  surface  looking  back- 
ward. In  this  position  bony  union  had  taken  place.  The  elongation  of  the  outer  half 
of  the  articular  end  of  the  humerus  accounted  for  the  gun-stock  deformity;  the  pres- 
ence of  the  large  mass  of  bone  dis- 
placed forward  by  tilting  of  the  frag- 
ment explained  the  inability  to  flex. 
The  lower  end  of  the  humerus  was 
pared  off  horizontally  with  the  knife, 
care  being  taken  to  remove  a  little 
more  from  the  external  than  from 
the  inner  half  of  the  lower  end  of 
the  humerus,  in  order  to  preserve 
the  "carrying  point."  The  capsule 
and  skin  were  united  by  suture. 
One  drainage  -  tube  was  inserted. 
The  arm  was  put  up  in  extension  in 
a  couple  of  lateral  pasteboard  splints. 
No  fever  followed.  Dec.  mh. — First 
change  of  dressings.  In  anaesthesia 
the  tube  was  removed,  and  the  arm 
was  flexed  to  an  acute  angle  and  put 
up  in  this  position  in  two  lateral 
pasteboard  splints.  Dec.  19th. — Pas- 
sive motion  was  practiced  in  anaes- 
thesia, and  the  arm  was  fixed  in  the 
straight  position.  Dec.  23d. — Passive 
motion  without  ether.  Fixation  at 
an  acute  angle.  Dec.  29th. — Free 
passive  motion  to  normal  limits. 
Splints  abandoned  and  active  move- 
ments commenced.  March  3d. — 
Outline  of  elbow  almost  normal. 
Flexion  and  extension  normal. 

Case  II. — Willie  H.,  aged  elev- 
en.   Very  pronounced  gun-stock  de- 
formity due  to  fracture  of  the  elbow- 
joint  sustained  two  and  a  half  years 
ago.     The  treatment  hud  been  conducted  by  a  surgeon  of  good  repute.     Flexion  could 
be  carried  to  a  right  angle,  extension  to  about  one  hundred  and  thirty  degrees.     Fig. 
T7  shows  the  boy's  arm  in  full  extension.   June  17,  1887. — Arthrotomy  done  at  Mount 


Fio.  77. — Gun-stoek  deformity  due  to  T-lracture  of 
the  lower  end  of  the  humerus.     Willie  11. 's  case. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


83 


Sinai  Hospital  revealed  a  very  curious  condition  of  things.  The  broken-off  external 
condyle  and  capitellum  occupied  a  position  similar  to  that  observed  in  the  preceding 
case.  The  ulna  was  dislocated  backward  and 
inward  from  the  fragment  representing  the  tro- 
chlea, which  was  attached  by  callus  to  the  an- 
terior aspect  of  the  lower  end  of  the  humerus. 
Apparently  a  T-shaped  fracture  of  the  lower 
end  of  the  humerus  had  taken  place.  The  ar- 
ticular surface  had  a  most  grotesque  shape.  The 
cartUaginons  surfaces  of  the  trochlea  and  sig- 
moid incisure  were  coated  with  a  dense  mass 
of  connective  tissue.  The  broken-off  coracoid 
process  was  attached  to  the  fragment  of  the 
trochlea.  The  articular  sui-face  was  pared  off 
to  approximate  the  shape  of  a  normal  hume- 
rus, and  the  wound  was  drained,  sutured,  and 
the  arm  put  up  in  a  pasteboard  splint.  Normal 
union  by  primary  adhesion  of  the  wound  took 
place,  but  an  annoying  complication,  consisting 
of  paralysis  of  the  forearm  and  hand^  was  noted. 
This  untoward  event  was  probably  caused  by 
the  fact  that  the  pad  of  Martin's  bandage,  used 
for  producing  artificial  anaemia,  had  been  placed 
over  the  inner  aspect  of  the  arm^  exerting  undue 
pressure  over  the  nerves.  June  19th. — The 
compressive  dressings  were  removed,  the  drain- 
age-tube was  withdrawn,  and  the  wound  re- 
dressed. July  Sd. — The  patient  was  discharged 
from  the  hospital  with  healed  wound.  Local 
treatment  of  paralvsis  by  galvanism  and  mas- 
sage was  commenced.     July  22d. — Flexion  and 

extension  of  forearm  and  fingers  re-established.     Aug.  1st. — Function  of  elbow  be- 
coming normal.     Aug.  19th. — Muscular  power  fully  restored.     (See  Fig.  78.) 

Habitual  luxation  of  the  s]ioulder-joi7it,  a  very  annoying  and  rebellious 
comi:)laint,  may  also  be  cured  by  arthrotomy  and  partial  exsection  of  the 
redundant  capsular  ligament.     (See  case  on  page  8,  Note  2.) 


Fict.  78. — Eesult  after  exsection  of  elbow- 
joint  for  gun-stock  deformity.  Willie 
"ll.'s  case. 


V.    OPERATIONS    FOR    DEFORMITIES. 

1.  Knock-Knee  and  Bow-Leg. — Operative  exposure  of  the  medullary  tissue 
of  the  long  bones  is  a  dangerous  procedure  unless  suppuration  can  be  ex- 
cluded from  the  wound.  By  the  successful  employment  of  the  aseptic 
method  the  danger  of  osteomyelitis  can  be  virtually  excluded. 

McEwen's  osteotomy  is  one  of  the  safest  and  most  useful  procedures  of  the 
newer  surgery.    It  has  almost  entirely  displaced  purely  orthopedic  methods. 

For  knock-knee,  after  division  of  the  soft  parts  by  a  short  longitudinal 
incision,  the  cancellous  tissue  of  the  lower  end  of  the  femur  is  divided  by 
a  properly  shaped  chisel,  called  osteotome.  For  bow-leg,  the  osteal  section 
is  carried  through  the  upper  end  of  the  shaft  of  the  tibia  and  fibula.     The 


84 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


operation  is  doue  under  artificial  anaemia  ;  and  the  dressings  are  aj)plied,  and 
the  limb  is  put  up  in  a  contentive  dressing — preferably  plaster  of  Paris — 
before  the  removal  of  the  constricting  elastic  band.  New-formed  bone  is 
thrown  out  into  the  gap  caused  by  the  correction  of  the  position  of  the  bones, 
and  bv  the  end  of  three  or  four  weeks  firm  union  in  a  normal  position  is 
the  result. 

Case. — Leopold  Heymann,  clerk,  aged  nineteen.  Very  marked  bow-legs,  the  dis- 
tance between  the  internal  condyles  of  the  femora  being  three  and  a  half  inches.  JSfo- 
remher  15,  1883. — Double  osteotomy  of  the  thighs  at  Mount  Sinai  Hospital.  Plaster- 
of-Paris  splints.  Dec.  IJ^th. — Change  of  dressings.  Wounds  healed  by  primary  union; 
bones  firmly  consolidated.  The  knees  were  in  contact,  but  the  curvature  of  the  tibiae, 
which  represented  a  great  part  of  the  deformity,  was  still  very  marked.  Undoubtedly 
osteotomy  of  the  shin-bones  would  have  given  a  better  result.  The  patient  declined 
further  operative  interference. 

3.  Bony  Anchylosis  in  a  vicious 
position. 

Case  I. — Lina  Frieberger,   aged  fif- 
teen.   Bony  anchylosis  of  right  and  pseud- 
anchylosis  of  left  maxillary  joint,  prob- 
ably due  to  acute  osteomyelitis  of  right 
ascending  ramus.     The  teeth  were  in  ab- 
solute apposition,  and  no  solid  food  could 
be  taken.     Marked   facial   hemiatrophy. 
In  childhood  a  suppurating  affection  of 
the   right   cheek   was   noted.     April  3, 
1886. — Exsection  by  chisel  and  mallet  of 
the  left  maxillary  joint  (hemiatrophy  of 
the    same    side). 
Tlie  operation  did 
not    relieve    the 
functional     trou- 
ble ;     the     joint 
was  found  pseud- 
anchylosed,     the 
cartilages     gone, 
andthecapitellum 
nearly    absorbed. 
The  wound  liealed 
by  primary  inten- 
tion.   April  29th. 
—  Exsection      of 
right      maxillary 
joint,  which  was 
found  firmly  an- 
chylosed.        The 

semilunar  incision  was  obliterated,  the  capitellum,  coronoid  process,  and  temporal  bone 
forming  one  solid  mass.  Immediately  after  its  removal  the  teeth  could  be  separated 
to  tlie  distance  of  an  inch  and  a  quarter.  Primary  union.  Perfect  restoration  of  func- 
tion noted  in  January,  1887. 


K 


Fio.  79. — Arrun.i?eraent 
of  nails  in  Maggie 
Schweizer'.s  case. 


Fig.  80.— Final  result  in  Maggie  Schweizer's 
case.  Cross-inarks  indicate  places  where 
nails  were  driven  in.     (Page  85.) 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


Case  II. — Maggie  Sclnveizer,  aged  fifteen.  Bony  anchylosis  of  knee-joint  at  a  riglit 
angle,  in  consequence  of  infantile  acute  osteomyelitis  of  tibia,  with  suppuration  of  knee- 
joint.  January  23,  1886. — At  the  German  Hospital,  excision  of  the  patella  and  of  a 
wedge-shaped  piece  of  bone,  with  preservation  of  the  epiphyseal  lines  of  femur  and 
tibia.  Transverse  cutaneous  incision,  as  for  knee-joint  exsection.  Division  of  the 
bones  by  the  saw,  after  peeling  off  of  the  periosteum.  The  sawed  surfaces  were  brought 
together,  and  their  fixation  was  secured  by  three  steel  nails,  which  were  driven  diag- 
onally through  the  tibia  and  femur  in  the  horizontal  plane — that  is,  from  the  lateral 
aspect  of  the  extremity.  The  locking  of  the  femur  and  tibia  was  so  firm  that  the  limb 
could  be  raised  and  handled  like  a  solid  staff.  The  application  of  the  dressings  was 
thereby  made  a  very  easy  procedure.  Pull  plaster-of- Paris  splint.  No  reaction  and  no 
fever  were  observed.  Fei.  23d. — First  change  of  dressings.  The  nails  and  two  drain- 
age-tubes inserted  at  the  operation  were  removed.  The  bones  were  found  firmly 
united.  Over  a  small  aseptic  dressing  a  light  silicate-of-soda  splint  was  applied,  and 
the  patient  was  directed  to  walk  on  crutches.  March  15th. — Discharged  cured  with 
light  silicate  splint.  May  10th. — Presented  herself  to  author,  walking  excellently  with 
the  aid  of  a  raised  sole.     Shortening,  two  and  a  half  inches. 

3.  Deformed  Callus. 

Case  I. — William  Paradies,  laborer,  aged  thirty-eight.  Deformed  callus  of  the 
lower  end  of  the  tibia  following  a  supra-malleolar  fracture  of  the  leg.  Radiating  pain 
issuing  from  the  site  of  the  deformity,  due  to  pressure  on  the  in- 
tegument, which  was  tightly  stretched  over  the  protruding  edge 
of  the  upper  fragment.  March  7,  1887. — The  deformed  bone  was 
exposed  and  chiseled  away  on  a  level  with  the  surface  of  the  dis- 
tal fragment.  Suture ;  no  drainage.  Primary  union.  March  21st. 
— Patient  discharged  cured  fi'om  the  German  Hospital. 

Case  II. — Ernst  Langer,  carpenter,  aged  forty-five.  Deformed 
callus  of  fibula.  August  29,  1885. — At  the  German  Hospital,  in- 
cision and  exsection  of  the  callus  by  chisel  and  mallet.  Apposi- 
tion and  fixation  of  the  fragments  by  a  strong  catgut  bone-suture. 
Primary  union.  Discharged  cured,  September  26,  1885,  with  firm 
consohdation. 

4.  Club-Foot  and  Pes  Valffus. — On  account  of  its  sim-    Fig.  si.— Defoi-med 

1  i     n      1     ji       J?  callus    01     low- 

phcity  and  the  excellent  results  reported  both  irom  er  end  of  tibia. 
abroad  and  at  home  after  its  practice,  Phelps's  operation  diel/^'^" 
seems  to  deserve  extended  trial.  It  consists  in  the  com- 
bination of  tenotomy  of  the  tendo  Achillis  with  a  free  division  of  all  the 
soft  tissues  situated  on  the  mesial  side  of  the  planta  pedis,  the  incision 
penetrating  down  to  the  bone  and,  if  necessary,  into  joints.  The  idea  of 
dividing  all  resisting  tissues  underlies  the  plan  of  procedure.  The  incis- 
ion includes  the  tibialis  anticus  tendon,  the  tendons  of  the  tibialis  posticus, 
flexor  digitorum  communis  longus,  flexor  hallucis  longus,  the  belly  of  the 
flexor  digitorum  brevis,  of  the  abductor  hallucis,  the  plantar  fascia,  the  long 
plantar  ligament,  the  deltoid  ligament,  the  nerves,  and,  if  unavoidable,  the 
vessels.  The  incision  need  not  be  a  very  long  one.  It  commences  just  in  front 
of  the  tip  of  the  inner  malleolus,  and  extends  downward,  according  to  the 
age  of  the  patient,  for  about  an  inch  or  two.  All  the  ]3arts  named  above 
can  be  easily  reached  from  the  wound  Avith  a  tenotomy  knife,  unless  they 
13 


86 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


are  in  tlie  direct  line  of  section,  when  they  are  diyided  with  the  scalpel. 
Preservation  of  the  integrity  of  the  plantar  artery  is  very  desirable,  on 
acconnt  of  the  avoidance  of  satnration  of  the  dressings  with  blood.     The 


tiG.  8:i. — Group  illustrating  an  operation  about  the  foot  or  ankle. 

operation  being  done  with  the  aid  of  Esmarch's  band,  all  the  tissues  can 
be  readily  identified  as  they  are  gradually  exposed  step  by  step.    The  internal 
plantar  artery  can  thus  be  seen  and  doubly  tied.     The  main  trunk  of  the 
artery  sweeps  in  a  long  curve  outward   to  the  ex- 
ternal side  of  the  sole,  and  is  out  of  the  line  of  sec- 
tion.     Should   it  be   divided  accidentally,  and  the 
blood  soil  the  dressings  at  once,  it  is  proper  to  re- 
move them,  to  reapply  Esmarch's  band,  to  enlarge 
the  incision,  and  to  find  and  deli- 
gate  the   cut  ends   of   the  vessel. 
In  extreme  cases  of  adults,  where 
the  bones  have  acquired  a  definitely 
vicious  shape,  osteotomy  or  wedge- 
shaped  excision  of  the  neck  of  the 
astragalus   must  be  added   to  the 
teno-myotomy   performed    in    the 
planta. 

The  author  was  surprised  to  see         Fig   8.3.— Drossini,'  fm-  \Vf)UiRls  of  ankle  and  foot. 

the  ease  with  which  even  great  de- 
formities could  be  corrected  after  the  division  of  all  tissues  mentioned  above. 
Of  course,  the  wound  is  a  wide  gaj),  which  is  widened  still  more  by  the  cor- 
rected position.     Its  healing  is  accomplished  by  the  "  organization  of  the 


SPECIAL   APPLICATION  OF  THE  ASEPTIC   METHOD. 


8' 


moist  blood-clot"  (Schede's  method).  As  soon  as  the  wound  luis  been  well 
cleansed  by  irrigation,  a  piece  of  rubber  tissue,  ])reviously  kept  immersed 
in  a  five-per-cent  solution  of  carbolic  acid  for  twenty-four  hours,  is  placed 
over  the  gap.  This  is  covered  with  a  few  strips  of  iodoform  gauze  and 
an  ample  dressing  of  sublimated  gauze.  While  the  foot  is  held  in  the  cor- 
rect position 
by  an  assist- 
ant, the  sur- 
geon applies 
over  the  asep- 
tic dressing 
a  silicate-of- 
soda  splint, 
and  over  this 
a  plaster-of- 
Paris    splint. 

While  the  j)laster  is  setting 
foot  is  held  with  force  in 
somewhat  overcorrected  posi- 
tion, which  will  allow  for  the 
slight  giving,  way  of  the  asep- 
tic dressing.  Then  Esmarch's 
band  is  removed,  and  the  feet 
are  held  in  the  vertical  posture 

for  an  hour  or  two  after  the  operation.     After  disappearance  of  passive 
hyperaemia  they  are  placed  on  a  pillow  in  the  horizontal  posture. 

In  a  fortnight  or  so  the  plaster-of-Paris  shell  is  cut  away ;  the  silicate 
splint  thus  exposed  is  finished  off  by  a  few  turns  of  crinoline  bandage  soaked 
in  silicate,  and  as  soon  as  it  is  dry  the  patient  is  allowed  to  walk  with  the 
aid  of  crutches.  In  about  four  weeks  after  the  operation  the  silicate  shoe 
is  split  on  top,  and  the  dressings  are  removed.  In  many  cases  the  wound 
will  be  found  cicatrized  over  by  this  time.  Should  this  not  be  the  case, 
however,  the  aseptic  dressing  and  silicate  shoe  must  be  reapplied.  When 
the  wound  is  perfectly  healed,  the  silicate  splint  can  be  replaced  by  a  well- 
fittinof  laced  shoe. 


Fig. 

Elevation  of  the  feet 
after  Phelps's  operation. 


XoTE. — The  silicate  shoe  must  not  include  more  than  about  one  third  of  the  leg 
not  to  prevent  treatment  of  its  debilitated  muscles  by  massage  and  electricity. 


in  order 


The  fear  that  the  severed  tissues  will  not  grow  together  properly  is  un- 
founded. Schede  had  the  opportunity  of  ascertaining  by  autopsy  the  exact 
re-establishment  of  the  physiological  relations  of  the  cut  tissues.  The  best 
proof  of  the  fact  is,  however,  the  restoration  of  the  function  of  the  cut 
parts. 

The  results  exhibited  by  Phelps  at  a  meeting  of  the  New  York  State 
Medical  Society  at  Albany  surpass  everything  the  author  has  seen  accom- 
plished by  any  surgeon  for  the  cure  of  this  deformity. 


88 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURQERY. 


Case. — Hiirr.v  Epstein,  sdiool-boy,  aged  twelve,  siittering  from  chronic  interstitial 
nephritis  as  a  consequence  of  scarlatina.  General  condition  poor,  on  account  of  lack 
of  exercise,  due  to  disaltility  trom  club-feet.     The  patient  was  walking  on  the  outer 

edge  of  the  plantas.  The 
urine  contained  granular 
and  hyaline  casts,  and 
twenty  per  cent  of  albu- 
men. March  lit,  1887.— 
At  Mount  Sinai  Hospital, 
double  Phelps's  operation 
was  done  under  chloro- 
form, wliich  was  borne 
excellently,  the  operation 
lasting  forty-five  minutes. 
No  fever,  no  reaction 
followed,  llarch  SSth.— 
The  plaster  shell  was  cut 
away,  and  the  patient 
commenced  to  hobble 
about  in  the  ward  on 
crutches.  April  10th. — 
The  old  water-glass  splints 
were  removed,  and  were 
replaced  by  a  new  set, 
which  were  worn  until 
June.     After  this  the  patient  was  fitted  with  a  pair  of  lacing  shoes. 

Case  II. — Aaron  Meyer,  oysterman,  aged  twenty-nine,  far  gone  and  very  painful 
p3s  valgus  of  both  feet.  Oct.  12,  1885. — At  Mount  Sinai  Hospital,  exsection  of  a  bony 
wedge  by  chisel  and  mallet  from  the  internal  aspect  of  the  head  of  the  astragalus, 
the  scaphoid,  and  calcaneum  of  the  right  foot.  Area  of  the  base  of  the  wedge  about 
one  square  inch.  The  remnants  of  the  neck  of  the  astragalus  and  calcaneum  were 
divided  entirely  by  the  osteotome,  and  the  foot  was  broken  into  shape  by  manual  force 
and  put  up  in  an  aseptic  dressing  and  plaster-of-Pai"is  splint.  Nov.  1st. — Dressings 
rerac>ved,  wound  presenting  a  strip  of  shallow  granulations.  Dec.  1st. — Discharged 
cured.  Feb.  1st. — Foulis's  operation  on  the  left  foot,  which  showed  a  lesser  degree  of 
deformity  than  the  right  foot  before  operation.  The  talo-navicular  joint  was  incised, 
and  its  entire  cartilaginous  covering  was  removed  by  scraping  with  a  scoop.  Fe/K  2Ut. 
— First  change  of  dressings;  primary  imion.  Feb.  27th. — Patient  discharged  cured. 
In  March,  1887,  patient  presented  himself  for  examination.  Firm  anchylosis  of  the 
talo-navicular  joints  of  both  sides,  and  very  good  function  had  been  secured,  the 
patient  attending  to  his  accustomed  business. 


Fig.  85. — Appearance  of  wounds  four  weeks  after  Phelps's 
operation.     Harry  Epstein's  case. 


VI.     PLASTIC    OPERATIONS. 

Aseptics  liave  greatly  improved  the  results  of  plastic  operations,  and 
especially  erysipelas  has  been  almost  entirely  banished  from  facial  wounds 
made  for  plastic  purposes.  In  performing  any  operation  about  the  face  it 
is  necessary  for  the  surgeon  to  protect  himself  and  the  patient  from  two 
sources  of  infection.  One  is  the  oral  and  nasal  secretions,  the  other  the 
patient's  head,  notably  his  hair.     The  latter  should  always  be  enveloped  in 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


89 


a  cap  extemporized  from  a  good-sized  towel  or  comjjrcss  wrung  out  of  cor- 
rosive-sublimate lotion.  The  accompanying  illustrations  show  the  manner 
of  folding  the  towel  about  the  head.     It  should  be  lirnily  fastened  by  a 

narrow  roller-bandage  encircling  the  forehead 
and  occiput.  Whenever  vomiting  occurs,  a 
careful  cleansing  of  the  soiled  skin  and  a 
ciiange  of  towels  are  indicated. 

Where  there  is  no  great  tension  to  be  over- 
come, fine  catgut  (No.  0)  makes  excellent  sut- 
uring material  for  facial  wounds  after  plastic 
operations. 

Where  the  tension  is  great  (which,  how- 
ever, should  be  reduced  to  a  minimum  by  the 

proper  shaping  of 
flaps  and  free  dis- 
section), silver  wire, 
or  silkworm  t  gut 
well  soaked  in  car- 
bolic lotion,  will  be 
well  employed  for 
retentive  purposes. 
Sutures  of  coapta- 
tion are  best  made 
with  fine  catgut. 

Hare  -  lip    pins 
were  never  used  by 
the  author,  as  they  are  unnecessary,  and  offer  no  advantages  over  the  sutur- 
ing material  more  generally  employed  by  surgeons. 

Where  the  wounded  surfaces  can  be  completely  closed  by  suture,  no 
dressings  whatever  are  needed.  A  thick  layer  of  iodoform  dusted  over  the 
line  of  union  will  soon  unite 
with  the  oozings  into  a  paste, 
which  on  becoming  dry  will 
form  an  excellent  and  un- 
irritating  protection  to  the 
wounds  and  suture-points. 
Daubs  of  collodion,  or  the 
application,  after  hare  -  lip 
operations,  of  strips  of  ad- 
hesive plaster  to  the  face, 
are  especially  unpleasant  and 

irritating  to  infants.      They  Fig.  87.— Applying  aseptic  cap.     Second  step. 

create  uneasiness,  and  excite 

the  little  patients  into  crying  fits,  and  the  distortion  of  the  face  resulting 
from  frequent  crying  is  certainly  not  conducive  to  the  uninterrupted  rest 
and  union  of  the  wounds. 


Fig.  86. — Applying  aseptic  cap.     First  step. 


90 


RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  88. — Aseptic  cap  in  situ.     Cancer  of  lip. 


Retentive  sutures  should  never  be  removed  too  soon — that  is,  before  the 
seventh  day.     The  smaller  catgut  sutures  will  be  absorbed  by  that  time. 

Where  an  uncovered  de- 
fect is  unavoidably  left  be- 
hind, on  account  of  lack  of 
integument  or  some  other 
reason,  Schede's  procedure  is 
the  best  means  of  preventing 
supjDuration.  A  strip  of  rub- 
ber tissue  is  laid  over  the  de- 
fect, and  is  suitably  inclosed 
in  an  aseptic  dressing.  The 
blood-clot,  which  will  form 
under  the  rubber  tissue,  will, 
if  it  be  well  protected  from 
desiccation  and  decomposi- 
tion, rajDidly  become  organ- 
ized. 
In  plastic  operations  performed  about  tlie  soft  and  hard  palate  the  con- 
dition of  the  teeth  should  be  well  attended  to  previous  to  the  undertaking. 
Decaying  teeth  should  be  removed,  and  an  unwholesome  state  of  the  gums 
and  mucous  membrane  should  be 
corrected  by  the  diligent  use  of  the 
tooth-brush  and  a  1:1,000  solution 
of  permanganate  of  potash  as  a 
mouth-wash. 

Urethroplasty  will  fail  almost  in- 
variably if  ammoniacal  urine  is  per- 
mitted to  pass  over  the  line  of  union. 
Acid  urine  is  not  deleterious  to  the 
wounds.  Where  chemical  examina- 
tion has  established  the  presence  of 
ammoniacal  decomposition  of  the 
urine,  frequent  washings  of  the  blad- 
der and  the  urethra  with  weak  so- 
lutions of  permanganate  of  potash 
(1  :  4,000  or  5,000)  and  the  internal 
administration  of  boracic  acid  will 
suitably  prepare  those  organs  for  the 
operation.  To  prevent  the  soiling 
of  the  wound  by  ammoniacal  urine, 
a  soft  Nelaton  catheter  should  be 
passed  into  the  bladder  and  fixed  by 

a  proper  bandage  to  prevent  its  escape.  Daily  antiseptic  irrigation  of  the 
bladder  should  be  continued  all  the  time  while  permanent  catheterism  is 
used.     As  soon  as  the  wound  is  firmly  united,  catheterism  may  be  stopped. 


Fk;.  b'.i. — Dressiiifi'  for  cxcisidu  of  the 
upper  jaw. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


til 


Periiwal  plastic  opcrntions  on  tlie  female  require  a  ])revioii.s  thorough 
disinfection  of  tlie  vulva  and  vagina  by  mercurial  irrigation,  which  should 
be  kept  up  during  the  entire  time  of  the  operation.  Here,  too,  dressings 
are  annoying  and  unnecessary.  Catheterism,  temporary  confinement  of  the 
bowels,  and  frequent  irrigation,  with  subsecjuent  dusting  with  iodoform 
powder,  will  afford  all  the  security  needed  against  infection. 

Aside  from  the  care  for  the  production  and  maintenance  of  the  aseptic 
condition  during  and  after  the  operation,  another  imj)ortant  requirement 
must  be  fulfilled.  This  is  a  thorough  and  complete  apposition  of  the  entirety 
of  the  wounded  surfaces  hy  several  tiers  of  catgut  sutures,  and  a  correct 
union  of  the  mucous  membranes  of  the  vagina,  and  of  the  rectum  if  necessary. 
A  slovenly  manner  of  suturing  will  lead  to  the  formation  of  hollow  spaces, 
which  will  become  filled  by  blood-clot ;  and,  if  the  sutures  of  the  mucous 
membranes  be  also  inexact,  contact  of  the  vaginal  or  rectal  discharges  with 
the  unprotected  clot  will  lead  to  its  inevitable  putrescence,  and  to  partial 
or  general  suppuration.  An  exact,  deep  and  superficial  suture  is  the  best 
protection  of  perineal  operative  wounds  against  infection. 

Note. — The  stitches  holding  tlie  mucous  membrane  together  should  never  pass  through  the 
epithelium.  They  should  be  entered  and  brought  out  just  below  the  epithelial  lining.  This 
will  prevent  inversion  of  the  edges,  and  the  stitch-holes  will  be  also  protected  from  infection  by 
the  ridge  of  proti'uding  mucous  membrane. 

On  account  of  the  great  vascularity  of  the  face,  facial  wounds  will  often 
heal  without  suppuration,  even  if  very  indifferent  asepticism  was  observed. 

Not  so  in  other  parts  of  the  body,  notably  about  the  extremities,  where 
suppuration  is  much  more  easily  produced,  and  is  generally  followed  by 
sloughing  of  the  flaps.  Strict  asepticism,  avoidance  of  tension  by  sutures 
and  of  pressure  by  dressings,  are  imperative  conditions  of  success  in  plastic 
operations  done  on  the  extremities. 


Fig.  90. 


-Maas's  operation.     Primary  plaster-of-Paris  dressina;s.     On  the  right  leg,  the  defect 
to  be  covered ;   on  the  lei't  leg,  flap  detached  from  calf. " 


Case  I. — Abraham  Strecker,  aged  seven.  Circular,  extensive  skin  defect  of  the 
right  leg,  due  to  old  compound  fracture:  extensive  ulceration  of  frontal  part  of  the 
cicatrix;  oedema  of  the  foot,  caused  by   contraction  of  the  circular  cicatrix.     Dee.  7, 


92 


RULES  OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 


ISSo. — At  Mount  Sinai  Hospital,  plastic  repair  of  the  frontal  part  of  the  defect  by  Maas's 
procedure.  Each  thigh  and  foot  was  first  incased  in  a  plaster-of- Paris  splint,  then  the 
cicatrix  was  disinfected  with  an  eight-per-cent  solution  of  chloride  of  zinc  and  pared  off 


Fig.  91. — Maas's  operation.     Secondary  plaster-of-Paris  dressings  fixing  relative  position   of 
extremities.     Flap  attached  to  its  new  habitat. 


with  the  scalpel.  After  this  a  properly  shaped,  generous  skin-flap  was  raised  from  the 
posterior  aspect  of  the  left  leg.  Now  the  extremities  were  superimposed  in  such  a  manner 
as  to  bring  the  flap  over  the  vivified  surface  of  the  right  leg,  wherewith  it  was  brought 

in  contact  on  its  raw  surface.  A  second- 
ary plaster-of-Paris  dressing  applied  over 
the  primary  plaster  splints  secured  the 
limbs  and  the  flap  in  their  new  relative 
position.  The  exposed  raw  surface  of  the 
pedicle  of  the  flap  was  wrapped  in  an 
envelope  of  rubber  tissue  to  prevent  its 
desiccation ;  the  flap  was  lightly  attached 
to  its  new  habitat  by  a  few  catgut  sut- 
ures. The  edges  of  the  flap  were  dust- 
ed vrith  iodoform,  and  the  defect  of  the 
calf  was  inclosed  in  an  aseptic  dressing. 
With  the  exception  of  a  small  portion 
of  the  end  of  the  flap  which  necrosed, 
primary  union  throughout  was  achieved. 
Dec.  21st. — The  pedicle  of  the  flap  was 
cut,  and  the  limbs  were  released  from 
their  confinement.  Rapid  cicatrization 
of  the  remnant  of  the  original  and  of  the 
defect  of  the  calf  followed,  and,  January 
30,  1886,  the  boy  was  discharged  cured. 
The  oedema  of  the  foot  had  disappeared. 
Case  II. — Adolph  Carstens,  school- 
boy, aged  eleven.  Fel.  17,  1887.— Av 
the  German  Hospital,  Maas's  operation 
for  a  large  skin  defect  of  the  anterior 
aspect  of  the  tibia,  due  to  severe  traumatism.  The  case  was  managed  exactly  like  the 
foregoing  one,  with  this  additional  circumstance,  however,  that  it  became  necessary 
to  pare  off  an  area  of  the  anterior  aspect  of  the  tibia  by  chiseling,  corresponding  to 


Fif..  02.— Maas's  op- 
eration, final  resiiit. 
Cicatrix  is  marked 
with  ink. 


Fig.  93. — View  of  ci- 
catrix of  the  phicc 
whence  the  skin-iiap 
was  taken. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.  93 

the  size  of  the  flap,  in  order  to  remove  the  condensed  cicatricial  tissue  underlying  the 
extensive  elevated  ulcer.  Thus,  a  well-vascularized  base  was  secured  for  the  skin-tiap. 
March  5(Z.— The  pedicle  was  divided,  and,  April  10th,  the  patient  was  discharged  cured. 

VII.     ASEPTICS    OF    THE    ORAL    CAVITY. 

Long  after  the  principles  of  tiie  aseptic  treatment  of  external  wounds 
had  become  recognized,  the  proper  management  of  the  wounds  of  the  nor- 
mal openings  of  the  resiDiratory,  digestory,  and  uro-genital  tracts  was  still  a 
mooted  question.  It  was  a  comparatively  easy  thing  to  produce  in  these 
regions  an  aseptic  condition  for  the  time  of  the  operation.  But  how  to 
protect  the  wounds  from  the  inevitable  soiling  by  the  continuous  discharges 
pertaining  to  these  several  apertures,  was  first  shown  by  Billroth,  who  suc- 
cessfully employed  iodoform  as  an  effective  preventive  of  putrefaction  in 
the  oral  cavity. 

If  a  fresh  wound  of  the  oral  cavity  is  rubbed  off  with  iodoform  powder 
and  packed  with  gauze  saturated  with  iodoform,  this  dressing  will  become 
matted  together  with  the  tissues  of  the  raw  surface,  and  will  form  an 
effective  protection  against  infection  by  septic  influences.  The  secretions 
will  innocuously  pass  over  the  surface  of  the  gauze,  and  the  penetration  of 
active  germs  to  the  wound  will  be  prevented  by  the  air-tight  and  closely 
adherent  packing. 

The  course  of  oral  wounds  treated  in  this  manner  differs  widely  from  that 
observed  under  other  forms  of  treatment.  Diphtheritic  and  phlegmonous 
processes,  formerly  so  common  in  wounds  freely  communicating  with  the 
mouth,  have  become  things  of  great  rarity.  The  terrible  odor  which  could 
not  be  kept  down  by  however  frequent  irrigations  with  any  kind  of  deodor- 
izing lotion  until  the  necrosed  layer  of  tissues  was  cast  off,  is  now  generally 
absent.  By  the  time  that  the  packing  of  iodoformed  gauze  becomes  loose, 
healthy  and  vigorous  granulations  will  have  sprung  up,  and  the  wound  will 
progress  toward  its  uninterrupted  healing  without  pain  and  without  fever. 

As  long  as  the  packing  is  firmly  adherent,  it  should  not  be  disturbed. 
Its  forcible  extraction  would  certainly  cause  a  good  deal  of  pain,  and  would 
be  followed  by  haemorrhage  and  inflammation.  The  superficial  layers  of 
iodoformed  gauze,  becoming  soiled  by  secretions  or  food,  can  be  daily 
renewed. 

Another  important  point  to  be  observed  in  operations  about  the  oral 
cavity  is  the  control  of  hgemorrhage.  The  abundant  blood-supply  of  this 
region  is  apt  to  be  the  source  of  copious  haemorrhage,  dangerous  in  itself, 
but  especially  perilous  on  account  of  the  possibility  of  the  entrance  of  blood 
into  the  air-passages. 

This  accident  may,  on  the  one  hand,  cause  instant  death  from  suffoca- 
tion ;  on  the  other,  it  may  produce  catarrhal  or  septic  pneumonia  by  decom- 
position within  the  bronchi. 

Hemorrhage  from  oral  wounds  can  be  controlled   in  two  ways.     They 
may  be  employed  separately  or  combined. 
14 


94 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  94. — The  author's  tracheal  tampon  cannula. 


The  first  one  is  by  preliminary  ligature  of  one  or  both  lingual  arteries  ; 
the  second,  by  the  exclusive  use  of  the  actual  cautery  and  galvano-caustic 
wire  loop. 

Where  the  operation  must  needs  extend  to  the  floor  of  the  mouth,  deli- 
gation  of  the  lingual  arteries  will  be  insufficient,  and  the  use  of  the  actual 
cautery  point  or  loop  often  impracticable.  In  such  a  ca,se,  preluninary 
tracheotomy  and  the  employment  of  a  tampon  can?mla  will  be  the  only  safe 

means  of  preventing 
the  entrance  of  blood 
into  the  bronchi. 

Although  White- 
head's speculum  is  an 
excellent  instrument 
to  render  the  oral  cav- 
ity accessible,  yet  it 
will  be  unsatisfactory 
in  operations  to  be 
done  on  the  floor  of 
the  mouth.  Here  sec- 
tion or  even  partial 
excision  of  the  lower 
jaw  may  be  unavoidably  necessary  to  afford  ample  space  for  complete  excis- 
ion of  a  malignant  tumor,  and  to  make  accurate  h^emostasis  practicable. 

Where  most  or  all  attachments  of  the  tongue  to  the  inferior  maxilla  must 
be  severed,  a  strong  loop  of  silk  should  be  drawn  through  the  stump  of  the 
tongue  near  the  epiglottis,  to  be  brought  out  by  the  mouth  and  attached 
by  a  strip  of  adhesive  plaster  to  the  cheek.  This  precaution  will  enable  the 
nurse  or  attendant  to  instantly  clear  the  epiglottis  should  the  stump  of  the 
tongue  ever  slip  back  upon  and  occlude  the  entrance  to  the  larynx. 

In  the  more  extensive  cases  of  oral  surgery,  especially  after  removal  of 
the  tongue,  nutrition  will  have  to  be  carried  on  for  some  time  by  the  stom- 
ach-tube, which  can  be  left  in  for  several  days,  or  can  be  daily  introduced 
by  the  mouth  or  nostril. 

Early  operations  for  cancer  of  the  tongue  will  give  better  results  in  every 
way  than  late  ones.  But  even  of  the  latter  it  can  be  said  that,  as  a  rule, 
the  patient's  life  will  be  prolonged  by  them,  and  will  be  made  more  tol- 
erable. 

Every  oral  operation  should  be  preceded  by  a  careful  preparation  of  the 
mouth  by  extraction  of  carious  teeth  and  frequent  washings  with  a  germi- 
cide lotion,  preferably  a  1  :  1,000  solution  of  permanganate  of  potash.  Pres- 
ent stomatitis  should  be  first  got  rid  of  by  all  means. 

Case  I. — Mr.  David  S.,  wholesale  butcher,  aged  fifty-four.  Strong  smoker.  On  the 
inner  aspect  of  the  right  clieek,  opposite  a  carious  and  sharp-edged  molar,  where  an 
opaline  mucous  patch  had  existed  for  some  time,  an  elevated  ulcer  of  the  size  of  a 
silver  dollar  had  established  itself,  and  was  steadily  extending.  The  submaxillary 
lymphatic  glands  were  intiimescent.    April  30,  1884- — Extirpation  of  the  growth  from 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.  95 

a  transverse  incision  extending  backward  from  the  angle  of  tlie  mouth.  Tlie  outer 
skin  was  saved  and  brouglit  togetlier  by  a  line  of  stitches.  The  intumescent  submax- 
illary glands  were  also  removed.  Uninterrupted  recovery  followed,  but  a  small  fistula 
remained  behind,  corresponding  to  the  middle  of  the  incision  of  the  cheek,  which,  how- 
ever, closed  after  a  few  applications  of  the  thermo-cautery.  The  contraction  of  the 
cheek  was  successfully  overcome  by  the  insertion  and  wearing  of  wooden  wedges,  which 
were  abandoned  in  the  fall  of  1884.  During  the  summer  a  relapse  of  cancer  had 
developed  in  the  deep-seated  submaxillary  glands  of  the  right  side  and  in  the  submen- 
tal gland.  September  S5,  1884- — The  glandular  swellings  were  extirpated  from  both 
mentioned  regions.  The  complete  removal  of  the  submaxillary  glands  necessitated 
excision  of  two  inches  of  the  deep  jugular  vein.  The  wound  healed  by  the  first  inten- 
tion; the  patient  took  his  first  walk  twelve  days  after  the  operation.  He  remained 
free  from  the  disease  until  September,  1885,  when  a  rather  rapid  swelling  of  the  sub- 
maxillary glands  of  tlie  left  side  was  observed.  Apparently  the  infection  had  extended 
to  the  opposite  side  of  the  neck  by  way  of  the  diseased  submental  gland.  The  original 
site  of  the  epithelioma  in  the  cheek  remained  intact  by  relapse.  October  22^  1885. — An 
attempt  was  made  to  remove  the  glandular  swelling  of  the  left  side  of  the  cheek,  but 
it  had  to  be  abandoned  on  account  of  the  wide  extension  and  infiltrating  character  of 
the  new  growth,  January  31,  1886. — Patient  died  of  extension  of  the  disease  to  the 
cerebrum. 

Had  the  first  operation  been  undertaken  at  an  earlier  date,  the  respite 
secured  to  the. patient  would  have  been  much  longer. 

Case  II. — Katie  Jobs,  aged  thirteen.  Mucous  cyst  of  the  left  under  side  of  the 
tongue,  deeply  imbedded  in  the  lingual  tissues,  and  extending  back  to  the  hyoid  bone. 
March  21^.,  1883. — Deligation  of  the  left  lingual  artery  from  an  external  incision  above 
the  hyoid  bone.  Whitehead's  speculum  being  inserted,  the  tongue  was  transfixed  and 
secured  by  a  strong  fillet  of  silk.  By  this  it  was  withdrawn,  and  the  cyst  was  easily 
extirpated  from  its  bed  by  means  of  scissors  and  forceps.  Care  was  taken  not  to  grasp 
the  cyst  with  the  mouse-tooth  forceps,  which  served  only  to  hold  aside  the  muscular 
tissue  of  the  tongue.  Minimal  haemorrhage  was  observed.  The  wound  was  stitched 
with  fine  silk  throughout  its  entire  length,  a  few  threads  of  catgut  being  inserted  into 
its  upper  corner  for  drainage.  Both  wounds  healed  by  primary  union,  and,  April  7th, 
the  patient  was  discharged  cured  from  the  German  Hospital. 

Case  III. — Adolph  Bottger,  cooper,  aged  forty-two,  a  strenuous  smoker  and  hard 
drinker,  had  contracted  an  epithelioma  of  the  right  anterior  margin  of  the  tongue,  ex- 
tending well  forward  to  the  gums  of  the  canine  tooth,  and  involving  the  intervening 
part  of  the  floor  of  the  mouth.  No  intumescence  of  the  lymphatic  glands  could  be 
made  out.  A^igust  28,  1883. — At  the  German  Hospital  the  right  lingual  artery  was 
deligated,  and  the  right  half  of  the  tongue  was  excised  by  the  aid  of  forceps  and  scis- 
sors. A  morphine  injection  had  been  administered  before  the  operation,  and  anaes- 
thesia by  chlorofoi-m  was  not  carried  to  insensibility.  Hemorrhage  was  very  moder- 
ate. In  excising  the  floor  of  the  mouth  the  bleeding  was  somewhat  profuse,  and  a 
large  number  of  spurting  vessels  had  to  be  tied.  The  resulting  wound  was  packed 
with  iodoformized  gauze.  No  fever  or  inflammation  followed,  and  the  power  of  deglu- 
tition was  re-established  on  the  third  day.  The  patient  left  the  bed  on  September  9th, 
and  October  9th  was  discharged  cured.  In  February,  1884,  the  disease  returned  on 
the  inner  aspect  of  the  gums.  March  10th. — Three  inches  of  the  alveolar  process  of 
the  horizontal  part  of  the  lower  maxilla  were  excised,  together  with  the  entire  cicatrix. 
Cure  was  delayed  by  necrosis  of  the  remaining  portion  of  the  body  of  the  jaw.  April 
30th. — The  sequestrum  was  extracted.     May  20,  I884. — Patient  was  discharged  cured. 


96  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

May  i7,  1886. — The  patient  returned  with  a  far-gone  relapse,  starting  from  the  left 
submaxillary  stump.  May  19th. — Exsection  was  performed.  Violent  delirium  tremens 
set  in  immediately  after  the  operation,  followed  by  death  in  collapse. 

Case  IV. — Fritz  Osterwald,  shoemaker,  aged  sixty-three;  strong  smoker;  cancer 
of  the  right  margin  of  the  tongue  well  back  near  the  anterior  pillar  of  the  fauces,  with 
considerable  involvement  of  the  floor  of  the  mouth,  February  ^,  1886. — Deligation 
of  the  left  lingual  artery,  followed  by  excision  of  the  corresponding  half  of  the  tongue 
and  floor  of  the  mouth  in  morphine-chloroform  anaesthesia  at  the  German  Hospital. 
Access  was  gained  to  the  oral  cavity  by  a  semicircular  incision  following  the  under 
side  of  the  lower  jaw,  from  which  the  attachments  of  the  muscles  were  raised  together 
with  the  periosteum.  The  mucous  membrane  was  cut  through,  whereupon  the  tongue 
and  floor  of  the  mouth  could  be  drawn  out  from  under  the  maxilla  and  turned  out  upon 
the  front  of  the  neck.  Hsemoi'rhage  was  rather  free  in  spite  of  the  preliminary  liga- 
ture of  the  lingual  artery ;  and,  though  the  patient  was  not  fully  ansesthetized,  alarm- 
ing asphyxia  suddenly  took  place,  apparently  due  to  the  occlusion  of  the  glottis  by  a 
blood-clot.  Efforts  to  dislodge  this  were  unsuccessful,  therefore  hasty  tracheotomy 
had  to  be  performed,  resulting  in  re-establishment  of  respiration.  After  this  the  excis- 
ion was  completed  without  further  mishap.  More  than  half  of  the  tongue  was  re- 
moved up  to  the  epiglottis,  together  with  the  left  side  of  the  floor  of  the  mouth  and 
the  anterior  faucial  pillar.  The  wound  was  packed  with  iodoformized  gauze.  Nutrition 
was  carried  on  by  stomach-tube.  No  fever  followed,  but,  February  15th,  symptoms  of 
iodoform  mania  necessitated  the  removal  of  the  original  packing,  which  was  replaced 
by  corrosive-sublimate  gauze.  Feh.  18th. — The  restless  patient  was  taken  to  his  home, 
whence  he  was  transferred  to  Bellevue  Hospital,  where  he  died  a  maniac  on  February 
28th. 

The  foregoing  case  illustrates  the  dangers  from  the  entrance  of  blood 
into  the  larynx,  and  the  greatest  drawback  of  iodoform  when  used  on  elderly- 
individuals — namely,  its  tendency  to  produce  acute  mania.  From  this 
instance  the  author  learned  the  lesson  of  never  risking  a  rather  bloody  opera- 
tion in  the  oral  cavity  without  preliminary  tracheotomy  and  the  use  of  a 
tampon  cannula.  The  anxious  moments  spent  in  opening  the  suffocating 
patient's  trachea  will  never  be  forgotten. 

Case  V. — Victor  Jeggi,  silk- weaver,  aged  fifty-three,  a  very  moderate  smoker, 
admitted  August  20,  1885,  to  the  German  Hospital  with  hngual  cancer,  involving  nearly 
one  half  and  principally  the  right  side  of  the  tongue.  No  glandular  swelling.  Aug. 
22.,  1885. — Both  lingual  arteries  were  deligated,  and  two  thirds  of  the  entire  length 
and  width  of  the  organ  were  excised  with  very  little  haemorrhage  in  mixed  (morphine- 
chloroform)  anaesthesia.  The  wound  was  packed  with  iodoformed  gauze.  Deglutition 
returned  on  August  28th.  The  wound  healed  very  rapidly,  so  that,  September  5th, 
])atient  could  be  discharged  nearly  cured.  He  presented  himself,  February  21,  1886, 
with  a  relapse  in  the  floor  of  the  mouth,  but  delayed  operation  until  March  30th,  when 
the  disease  had  assumed  formidable  proportions.  Preliminary  tracheotomy  being  done, 
the  author's  tampon  canula  was  inserted.  The  middle  portion  of  the  lower  jaw  was 
excised,  and  the  remnant  of  the  tongue  was  removed  together  with  the  entire  floor  of 
the  mouth  by  means  of  the  thermo-caustic  knife.  The  stumps  of  the  severed  arteries 
did  not  retract  (atheromatosis),  and  were  successively  tied.  The  wound  was  packed 
with  iodoformized  gauze,  and  nutrition  was  carried  on  by  the  stomach-tube.  April 
2d. — The  patient  vomited,  and  undoubtedly  some  of  the  ejecta  found  their  way  into 
the  bronchi.     April  3d. — Catarrhal  pneumonia  set  in  with  a  chill  and  a  temperature 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.  97 

of  104°  Fahr.  April  6th. — The  critical  condition  changed  for  the  belter,  and  by  April 
15tb  the  patient  left  the  bed.  To  avoid  vomiting  produced  by  the  frequent  introduc- 
tion of  the  stomach-tube,  this  was  carried  in  through  the  nostril  and  left  in  situ  with 
evident  comfort  to  the  i)atient.  The  wound  contracted  rapidly,  but  in  the  middle  of 
May  relapse  appeared  in  the  pharynx,  which  ended  the  patient's  existence  in  June,  1880. 

The  presence  of  the  tampon  cannula  in  the  trachea,  effectually  shutting 
off  the  possibility  of  the  entrance  of  blood  into  the  air-passages,  made  this 
otherwise  very  bloody  and  formidable  operation  comparatively  easy  and  safe. 

Case  VI. — Mr.  Joseph  T.,  wholesale  liquor-dealer,  aged  sixty,  a  smoker,  had  been 
suffering  for  twelve  years  from  opaline  patches  of  the  tongue,  two  of  which,  situated 
on  the  left  side  of  the  organ,  developed,  toward  the  end  of  1886,  into  epitheliomata. 
The  otherwise  well-nourished  patient  suffered  also  from  chronic  interstitial  nephritis, 
as  evidenced  by  the  presence  of  albumen  and  hyahne  and  fine  granular  casts  in  the 
urine.  Feb.  10,  1887. — The  left  lingual  artery  was  deligated  under  chloroform  anaes- 
thesia. The  tongue  was  secured  by  a  strong  fillet  of  silk,  and  was  withdrawn  from  the 
mouth.  A  straight  Peaslee's  needle  was  then  carried  into  the  bottom  of  the  deligation 
wound,  and  was  thrust  through  the  middle  of  the  base  of  the  tongue  just  in  front  of 
the  epiglottis  into  the  oral  cavity.  One  end  of  a  platinum  wire  was  passed  through  the 
eye  of  the  needle,  withdrawn  through  the  wound  and  disengaged.  The  same  needle 
was  reintroduced  by  the  wound  into  the  oral  cavity,  emerging  this  time  just  alongside 
of  the  left  anterior  pillar  of  the  fauces.  The  other  end  of  the  wire  was  brought  out 
by  the  needle  through  the  external  wound.  Thus,  one  half  of  the  base  of  the  tongue 
was  included  in  a  loop,  and,  the  wire  being  connected  with  a  galvanic  battery,  was 
singed  through  without  loss  of  blood.  After  this  the  tongue  was  divided  longitudi- 
nally by  the  thermo-cantery  in  two  unequal  halves,  and  finally  was  severed  from  its 
connections  with  the  floor  of  the  mouth  by  the  same  instrument.  A  few  spurting 
arteries  had  to  be  tied  off  during  this  last  step  of  the  operation,  which  was  completed 
within  the  time  of  forty  minutes.  The  haemorrhage  was  really  insignificant,  to  which 
circumstance  is  to  be  mainly  attributed  the  rapid  recovery  of  the  patient.  The  oral 
wound  was  packed  with  iodoformized  gauze,  and  the  external  incision  was  dressed  in 
the  normal  manner.  The  temperature  remained  normal  throughout,  and  feeding  by 
tube  was  discontinued  on  the  third  day.  The  mouth  was  irrigated  every  hour  with  a 
1 : 1,000  permanganate  of  potash  solution,  until  February  18th,  when  the  packing  came 
away.  The  wound  appeared  clean,  and  rapid  contraction  was  manifest.  Fe^.  25th. — 
The  external  wound  was  firmly  healed.     March  8th. — The  oral  wound  was  closed. 

Note. — la  preparing  iodoformized  gauze  for  use  in  wounds  of  the  oral  cavity  of  elderly 
subjects,  care  must  be  taken  not  to  sprinkle  too  much  of  the  chemical  upon  the  gauze.  The 
surplus  of  iodoform  should  be  rinsed  out  of  the  meshes  of  the  fabric,  which  should  be  tinged  just 
a  very  faint  yellow  color. 

VIII.     LARYNGEAL    OPERATIONS. 

1.  Tracheotomy. — The  belief  that  tracheotomy  is  an  easy  operation  is  by 
no  means  justified  by  the  author's  experience.  Occasionally,  on  a  slender 
neck,  and  when  there  is  competent  assistance  to  be  had,  it  is  a  simple 
enough  procedure.  But  in  most  cases,  especially  on  children,  it  calls  for 
the  best  qualities  of  an  experienced  and  cool  surgeon. 

The  necessity  of  tracheotomy  having  become  manifest,  three  require- 
ments are  to  be  fulfilled.     First,  infection  of  the  wound  has  to  be  avoided  ; 


98 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


secondly,  unnecessary  hfemorrhage  has  to  be  guarded  against ;  and,  tliirdly, 
the  trachea  has  to  be  properly  incised,  and  the  cannula  properly  introduced 
and  secured. 

The  risks  of  the  operation  are  not  inconsiderable,  hence  intubation  of 
the  larynx,  a  much  simpler,  easier,  and  more  physiological  procedure,  must 

be  declared  to  be  far  preferable  to  tracheotomy 
where  its  application  is  proper,  as  in  croupous 
laryngitis. 

For  the  removal  of  foreign  bodies  and  in  cases 
of  tumor  of  the  larynx,  tracheotomy  will  remain 
the  proper  measure. 

Avoidance  of  infection  of 
the  wound  from  within  or 
without  is  an  ever  important 
matter  in  all  laryngeal  op- 
erations. But  it  is  especial- 
ly important,  and  also  more 
difficult,  in  cases  where  the 
operation  is  done  in  the  pres- 
ence of  an  infectious  process, 
as,  for  instance,  diphtheritic 
croup,  where  the  extension 
of  the  septic  condition  to 
the  external  wound  signal- 
izes a  very  grave  complication  of  the  otherwise  precarious  state  of  the 
patient. 

The  aseptic  rules  laid  down  in  preceding  parts  of  this  work  obtain  to 
their  full  extent  in  laryngeal  operations.  Infection  from  within  must  be 
guarded  against  by  careful  cleansing  of  the  external  wound  and  rubbing 
iodoform  powder  into  all  its  recesses  before  incising  the  trachea.  As  soon 
as  the  cannula  is  inserted,  the  external  wound  must  be  well  mopped  out  with 
a  sponge  soaked  in  corrosive-sublimate  lotion.  Then  it  is  dusted  with  iodo- 
form, and  lightly  packed  with  iodoformized  gauze.  In  all  cases  of  croup 
the  external  wound  should  not 
be  sutured,  as  sutures  favor  re- 
tention. A  small  slit  compress 
of  iodoformized  gauze  is  slipped 
in  under  the  flange  of  the  can- 
nula before  its  fastening  by  the 
two  lateral  pieces  of  tape.  By 
slipping  in  over  the  gauze  com- 
press a  slit  piece  of  rubber  tis- 
sue or  oiled  silk,  the  dressings  and  the  patient's  shirt  will  be  protected  from 
soiling  by  the  sputa.  A  narrow  roller  bandage  passed  several  times  over  and 
under  the  outer  opening  of  the  cannula  will  give  additional  security  against 
accidents. 


Fig.  95. — Arrangement  of  the  patient  for  tracheotomy. 


Same  in  situ. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.  99 

Note. — Unruly  children  will  sometimes  attempt  the  forcible  removal  of  the  cannula.  In 
1880  the  author  performed  tracheotomy  on  a  boy  twelve  years  old,  who,  on  regaining  conscious- 
ness, at  once  tore  out  the  cannula  from  the  wound,  breaking  its  fastenings  to  the  flange,  which 
remained  attached  to  his  neck.  The  family  attendant,  an  elderly  gentleman,  attempted  the 
re-introduction  of  the  instrument.  Finally,  during  the  violent  struggles  of  the  patient  the 
cannula  slipped  into  place,  whereupon  respiration,  which  had  been  labored  before,  suddenly 
ceased  altogether.  The  author  reached  the  bedside  by  this  time,  and  at  once  removed  the 
cannula  from  the  asphyxiated  child's  neck,  restoring  respiration.  It  was  found  that  the  cannula 
had  been  introduced  upward  into  the  oral  cavity,  instead  of  downward  into  the  trachea.  Another 
tracheal  tube  was  properly  introduced,  and  peace  was  once  more  restored,  but  the  boy  died  sub- 
sequently of  septicaemia,  due  to  the  wide  extent  of  the  diphtheritic  affection  of  the  pharynx. 

Hcemorrliage,  always  characteristic  of  an  overhasty  and  bungling  opera- 
tion, can  be  guarded  against  by  observing  the  rules  laid  down  in  the  chaj)ter 
on  the  technique  of  surgical  dissection.  Nothing  will  retard  the  perform- 
ance of  tracheotomy  as  effectively  as  the  disregard  for  haemorrhage.  And 
every  drop  of  blood  spilt  unnecessarily  will  proportionately  diminish  the 
chances  of  recovery,  not  to  mention  the  danger  of  suffocation  from  the 
entrance  of  blood  into  the  langs. 

Note. — The  author  once  assisted  a  colleague  who  in  his  anxiety  to  open  the  trachea  cut 
the  isthmus  of  the  thyroid  gland.  The  formidable  haemorrhage  following  this  step  only  increased 
the  doctor's  haste.  He  plunged  the  knife  into  the  pool  of  blood  and  fortunately  opened  the 
trachea.  The  patient  aspirated  a  large  quantity  of  blood,  and  would  have  surely  been  suffocated 
but  by  the  timely  turning  of  his  body  face  downward.    The  patient,  a  boy  of  seven  years,  recovered. 

As  soon  as  the  skin,  platysma,  and  superficial  fascia  have  been  amj^ly 
divided,  the  two  groups  of  longitudinal  muscles  situated  in  front  of  the 
larynx  are  exposed.  Sharp  retractors  are  inserted  and  the  bleeding  vessels 
are  attended  to.  A  faint  white  mark  indicating  the  median  line  where 
the  muscles  meet,  is  incised,  and  the  muscles  are  taken  up  and  raised  by  the 
retractors  as  the  wound  deepens. 

Thus  far  everything  is  easy.  The  most  difficult  part  of  the  operation 
consists  in  the  proper  treatment  of  the  isthmus  of  the  thyroid  gland. 

The  surgeon  must  decide  whether  to  approach  the  trachea  from  above  or 
below  the  isthmus,  and  this  decision  depends  upon  the  length  of  the  neck 
and  the  size  of  the  isthmus.  In  long,  slender  necks,  the  trachea  is  easily 
exposed  below  the  isthmus  ;  in  short,  fat  necks,  with  a  massive  isthmus,  the 
upper  operation  is  more  appropriate. 

a.  SuPEEiOR  Tracheotomy. — Having  chosen  the  upper  o]3eration,  the 
surgeon  must  find  his  way  to  the  upper  part  of  the  trachea,  situated  just 
behind  the  isthmus,  without  injuring  the  thyroid  capsule  and  its  compli- 
cated plexus  of  large  and  turgid  veins.  To  accomplish  this,  Bose's  method 
affords  an  easy  way. 

The  deep  cervical  fascia  divides  into  two  layers  just  above  the  superior  margin  of 
the  thyroid  gland,  these  two  layers  forming  the  main  body  of  the  thyroid  capsule. 
The  point  of  division  corresponds  exactly  with  the  upper  margin  of  the  cricoid  carti- 
lage, which  can  be  easily  identified  by  touch.  The  nail  of  the  left  index-finger  is 
placed  against  the  margin  of  the  cricoid,  the  pulp  of  the  finger  looking  downward, 
whereby  the  thyroid  gland  is  protected,  and  the  fascia  is  opened  by  a  short  transverse 


100 


RULES   OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


Fig.  97. — Diagram  showing  relations 
of  deep  cervical  fascia,  a,  Thy- 
roid body.  Just  above  it,  corre- 
sponding to  cricoid  cartilage,  bi- 
furcation of  deep  cervical  fascia. 


iuoision  directed  against  the  upper  edge  of  tlie  cartilage.  As  soon  as  this  is  done,  a 
bhint  liook  can  be  iiitrodiu-ed  through  the  ti-ansverse  slit  behind  the  thyroid  gland, 
AAhii-h  then  can  be  drawn  down  with  some  force,  exposing  the  two  or  three  upper  rings 

of  the  trachea.  The  author  never  saw  this  method 
fail,  and,  in  employing  it,  never  was  compelled  to 
cut  the  cricoid  cartilage  for  want  of  space  to  limit 
the  incision  to  the  trachea.     (See  Fig.  97.) 

b.  Infekior  Tracheotomy. — When  the 
lower  operation  is  decided  on,  the  two  layers 
of  the  deep  cervical  fascia  are  successively 
incised  ietween  two  forceps,  and  thus  the 
trachea  will  be  readily  exposed. 

Incision  of  the  trachea  should  be  done 
by  the  scalpel  used  for  the  first  part  of  the 
operation,  and  rather  by  cutting  than  by 
puncture,  as  the  latter  may  injure  the  poste- 
rior wall  of  the  cylinder.  Before  cutting  it, 
the  trachea  should  be  allowed  first  to  adjust 
itself  in  its  normal  position,  so  that  the  in- 
cision should  be  placed  exactly  in  the  me- 
dian line. 

Grasping  of  the  trachea  while  the  incision  is  being  made,  but  especially 
haste  in  opening  the  organ,  may  lead  to  very  serious  mistakes.  It  may 
happen  that  the  trachea  is  not  incised  at  all,  or,  what  is  still  worse,  the 
incision  is  placed  laterally  or  even  posteriorly  on  the  tilted  wind-pipe. 

Case  I. — Mary  R.,  aged  five.  May  jf,  1882. — Tracheotomy  performed  by  a  col- 
league for  laryngeal  croup.  The  cannula  could  not  be  kept  back  in  the  wound,  and  the 
patient  was  found  by  the  author  suffocating,  the  instrument  lying  on  the  outside  of  the 
neck.  Examination  showed  that  the  tracheal  incision  was  placed  to  the  left  side  and 
posteriorly,  the  trachea  being  twisted  and  bent  while  the  cannula  was  in  situ.  An 
anterior  tracheal  incision  was  made,  and  in  this  the  tube  was  retained  without  trouble. 
The  child  died  of  pneumonia. 

Case  II. — Hermann  Mollenhauer,  aged  two  and  a  half.  Croupous  laryngitis. 
March  ^7,  1881. — With  the  assistance  of  the  family  attendant.  Dr.  Hase,  superior 
tracheotomy,  on  account  of  imminent  suffocation.  The  trachea  was  exposed  without 
trouble,  but  in  cutting  it  open  too  hastily  it  tilted  around  its  axis,  and  the  point  of  the 
knite  shaved  off  a  segment  of  the  first  tracheal  ring.  The  tilting  of  the  trachea  was 
not  noticed  at  first  on  account  of  the  necessary  haste ;  but,  as  soon  as  it  was  discovered, 
the  trachea  was  properly  incised,  and  the  child  ultimately  recovered. 

As  soon  as  the  proper  number  of  rings  are  divided,  the  lips  of  the  in- 
cision should  be  taken  uji  by  two  small,  sharp  retractors.  (See  Fig.  18, 
page  39.)  Hasty  crowding  in  of  the  cannula  is  reprehensible,  and  may 
cause  serious  or  fatal  mischief  by  detaching  and  pushing  membrane  down 
into  the  deeper  parts  of  the  tracheal  tube.  Drawing  asunder  the  tracheal 
wound  will  afford  ample  opportunity  for  free  breathing,  for  ejection  of  blood 
and  membrane  or  mucus,  and  will  give  the  surgeon  a  welcome  chance  to 
inspect  the  trachea  and  to  extract  semi-detached  membrane  or  a  foreign 


SPECIAL  APPLICATION   OP  THE  ASEPTIC   METHOD.        101 

body.     It  will  iilso  solve  the  question  whether  tracheotomy  has  accomplished 
its  end  or  not  by  the  relief  from  dys})noea. 

The  apncea,  or  seeming  cessation  of  breathing,  often  observed  imme- 
diately after  the  incision  of  the  trachea,  is  apt  to  alarm  beginners.  It  is 
due  to  the  habituation  of  the  patient  to  exist  on  a  very  small  allowance  of 
oxygen.  The  first  deep  and  free  breath  taken  through  a  newly-made 
tracheal  incision  gives  the  patient  more  oxygen  than  ten  or  fifteen  labored 
inspirations  could  give  before  the  operation. 

As  soon  as  the  cannula  and  dressings  are  in  place,  the  patient  is  brought 
to  bed,  and  a  sponge,  hollowed  out  in  cup  shape  by  the  curved  scissors,  is 
attached  with  a  safety-pin  or  two  to  a  suitable  piece  of  bandage,  is  wrung 
out  of  hot  carbolic  lotion  (two  per  cent),  and  is  tied  down  loosely  Just  over 
the  orifice  of  the  cannula.  It  should  be  cleansed  at  frequent  intervals 
in  the  same  lotion.  Close  attention  to  the  cleanliness  of  the  interior  of 
the  cannula  is  a  constant  duty  devolving  upon  the  nurse.  It  should  be 
done  by  chicken  or  pigeon  wing-feathers  dipped  in  carbolic  lotion.  The 
little  patients  should  be  encouraged  to  drink  as  much  as  possible,  prefer- 
ably milk. 

The  first  dressings  can  remain  undisturbed  for  three  days  ;  on  the  fourth 
day  they  and  the  cannula  are  changed.  The  patient  is  laid  out  flat  on  a 
table  as  for  tracheotomy,  and  everything  possibly  needed  should  be  at  hand 
and  readily  arranged  in  a  pan.  Two  shai'p  retractors,  thumb-forceps,  scis- 
sors, a  clean  cannula,  and  a  change  of  dressings  will  be  needed.  The  bandages 
are  cut,  and  they  and  the  cannula  are  simultaneously  removed  with  the  outer 
compress  of  gauze.  The  deeper  packing  should  remain  unchanged  till  it 
becomes  detached.  The  fresh  cannula  is  slipped  in  at  once,  and  usually  with- 
out much  difiiculty  if  the  procedure  be  not  unduly  delayed. 

The  packing  of  iodoformed  gauze  will  become  loose  on  about  the  fourth 
day,  and  should  then  be  removed.  If  the  wound  is  found  clean  and  granu- 
lating, no  repacking  will  be  required. 

As  soon  as  the  patient  can  breathe  freely  through  the  fenestrum  of  the 
outer  tube,  the  external  opening  of  the  cannula  being  occluded,  the  instru- 
ment should  be  removed,  as  it  is  apt  to  cause  pressure-sores  and  trouble- 
some granulations  within  the  trachea. 

The  author's  experience  embraces  thirty-eight  tracheotomies  performed 
for  various  reasons.  Twenty-two  were  done  for  croupous  laryngitis  on  chil- 
dren. Of  these,  five  recovered  ;  seventeen  died.  The  superior  operation 
was  employed  seventeen  times  ;  the  inferior,  five  times. 

One  of  the  children  died  of  suffocation  caused  by  the  ill-advised  action 
of  the  father,  who  inflated  the  patient's  bronchi  through  the  cannula  with 
a  large  quantity  of  burnt  alum.  The  others  died  of  extension  of  the  pro- 
cess to  the  lungs,  or  of  septicaemia. 

Of  the  remaining  sixteen  tracheotomies  done  on  non-croupous  cases,  two 
concerned  children,  fourteen  referred  to  adults. 

The  following  table  will  elucidate  the  causes  for  which  the  operation  was 
performed  : 
15 


102  RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Recovered.    Died, 

Asphyxia  from  entrance  of  blood  into  trachea 1  1 

"  "     malignant  goitre 2 

"  "     arterial  haemorrhage  into  a  cervical  abscess 1 

"  "     chloroform 1 

Dyspnoea  from  cicatricial  stenosis  of  bronchus 1 

"  "  "  "      pharynx 1 

"  "     foreign  body  in  trachea 1 

"  "  "  "     larynx 2 

"  "     laryngeal  tumor 3  1 

Preliminary  tracheotomy 1 

Total 9  7 

Of  the  two  cases  operated  on  for  the  entrance  of  blood  into  the  larynx, 
one  recovered  (see  Case  IV  on  page  96)  ;  the  other,  where  haemorrhage  came 
from  a  suicidal  gunshot  wound  of  the  base  of  the  skull,  died  of  the  cerebral 
injury. 

In  two  cases  the  operation  was  done  for  threatening  asphyxia  by  growing 
malignant  goitre.  Both  died  :  one  from  collapse  ;  the  other  from  coma, 
produced  by  acute  alcoholism  or  traumatic  delirium  (see  Cases  I  and  II  on 
page  109). 

In  one  case  asphyxia  caused  by  haemorrhage  into  a  cervical  abscess  neces- 
sitated the  operation.     Patient  recovered  (see  Case  III  on  page  217). 

In  two  cases  tracheotomy  was  done  without  success  for  deep-seated  ste- 
nosis of  the  air-ducts. 

One  concerned  a  man  of  forty,  in  whose  left  bronchus  post-mortem  examination 
revealed  a  syphilitic  cicatricial  stenosis.  The  other  bronchus  was  found  compressed 
by  acute  swelling  of  a  bronchial  lymphatic  gland. 

The  other  case  was  that  of  Fred.  Peckary,  aged  one,  who  exhibited  symptoms  of  a 
growing  tracheal  stenosis,  principally  obstructing  expiration.  The  case  came,  March 
6,  1886,  under  the  author's  care  by  the  kindness  of  Dr.  Boldt.  Tracheotomy  was  done 
at  the  German  Hospital  without  relief.  The  child  died  of  pneumonia  March  10th.  On 
autopsy  a  brass  trousers-button  was  found  imbedded  in  old  cicatricial  tissue  between 
trachea  and  oesophagus,  midway  between  the  cricoid  cartilage  and  the  bifurcation.  An 
open  communication  existed  between  the  two  tubes.  The  button  was  held  in  place  by  a 
rim  of  cicatricial  tissue  in  the  oesophagus,  and  projected  downward  with  its  free  lower 
margin  like  a  valve  into  the  lumen  of  the  trachea.  Thus  inspiration  found  no  impedi- 
ment, but  on  expiration  the  valve  was  raised,  and  expiration-stenosis  was  the  result. 

In  one  case  syphilitic  stricture  of  the  fauces  indicated  the  operation. 
Patient  survived. 

In  four  cases  the  trachea  was  opened  on  account  of  the  presence  of  laryn- 
geal tumors.  Three  survived,  and  one  died  of  septic  pneumonia,  due  to 
aspiration  of  the  intensely  fetid  secretion  of  the  ulcerated  tumor. 

Preliminary  tracheotomy  was  done  once  successfully  before  extirpation 
of  the  cancerous  tongue  (see  Case  V  on  page  90). 

In  one  case  the  trachea  was  opened  on  account  of  acute  asphyxia  occur- 
ring during  chloroform  anaesthesia. 

Case. — Undersized  boy,  aged  nineteen.  November  IS,  18S/>. — At  Mount  Sinai  Hos- 
pital removal  of  an  enormous  congenital  teratoma  of  tlie  occipital  region  under  chloro- 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        103 

form.  The  growtli  had  become  sarcomatous,  and  extensive  involvement  of  the  cervical 
glands  of  both  sides  was  present.  The  patient  had  to  be  placed  in  the  prone  position, 
and  this  and  his  generally  weak  state,  together  with  the  encroachment  on  the  trachea  by 
the  glandular  swellings,  produced  asphyxia  toward  the  end  of  the  operation.  As  arti- 
ficial respiration  did  not  seem  to  produce  any  effect,  tracheotomy  was  performed  at 
once,  and  respiration  was  restored.  While  the  pedicle  of  the  tumor  was  being  de- 
tached, it  was  noted  that  respiration  had  again  ceased.  The  cannula  was  found  outside 
of  the  tracheal  wound,  from  which  it  was  allowed  to  slip  by  the  assistant  intrusted 
with  the  narcosis.  It  is  fair  to  state  that  death  was  very  likely  due  to  exhaustion  or 
collapse  induced  by  the  shock  of  the  formidable  operation  upon  the  much  emaciated 
patient.     He  was  a  lad  of  nineteen,  but  looked  like  a  very  sickly  child  of  ten. 

In  one  case  increasing  stenosis,  caused  by  the  presence  of  a  dispropor- 
tionately small  tumor,  indicated  the  operation. 

Case. — Julius  Meyer,  peddler,  aged  thirty-nine.  Previous  history  pointed  at  the 
lodgment  of  a  foreign  body  in  the  oesophagus  with  dysphagia,  which  spontaneously 
disappeared.  Gradually,  however,  increasing  dyspnoea  supervened.  The  laryngoscope 
demonstrated  the  presence  of  a  small  irregular  tumor  in  the  larynx,  the  size  of  which 
did  not  seem  to  explain  the  intense  dyspnoea.  Tracheotomy  was  done  December  18, 
1886,  at  Mount  Sinai  Hospital.  On  incising  the  trachea  above  the  thyroid  body,  a 
granuloma  occupying  the  posterior  and  lateral  aspect  of  the  larynx  just  below  the  vocal 
chords  was  exposed.  Surrounded  by  this  mass  was  found  the  point  of  a  wooden  skewer^ 
one  inch  in  length,  its  ends  being  Imbedded  in  the  mucous  membrane.  The  cricoid 
cartilage  was  divided,  the  body  was  extracted,  and  the  granuloma  was  excised.  Dec. 
27tJi. — Tracheal  tube  was  removed.     (For  continuation,  see  Case  III  on  page  104.) 

The  following  history  of  the  removal  of  a  foreign  body  from  the  larynx 
of  a  child  concludes  the  series  of  the  author's  non-croupous  cases  of  trache- 
otomy : 

Case.— Clara  V.,  aged  five  and  a  half.     May  22,  1881. —k  foreign  body  entered 
the  larynx  of  the  patient,  causing  intense  fits  of  coughing  and  transient  attacks  of  chok- 
ing.    A  number  of  unsuccessful  attempts  at  endolaryngeal  removal  of  the  body  were 
made  the  same  day.     Finally,  the  body  became  lodged  in  the  right 
bronchus,   where  its  presence   was  made  out  by  the  sibilant  noise 
heard  near  the  bifurcation  and  the  absence  of  normal  respiration 
sounds  over  the  entire  right  lung.     A  short,  hacking  cough,  moder- 
ate dyspnoea,  and  noisy  respiration  served  as  constant  reminders  of 
the  impending  danger.     June  IJ^th. — During  a  coughing  spell,  sud- 
denly an  alarming  asphyctic  attack  set  in,  followed  by  dysphagia,       Fig.   98.— Min- 
aphony,    hoarse,   croupy  cough,   and   distressing  dyspnoea.     Marked         moved '^ from 
larnygeal  stridor  and  diminished  respiration  sounds  over  both  lungs         larynx  by  tra- 
pointed  to  the  lodgment  of  the  foreign  body  in  the  glottis.     Inferior         Exa°df  size. 
tracheotomy  being  performed,  the  dyspnoea  at  once  disappeared.    The         (Clara  V.) 
foreign  body,  a  headless  and  armless  miniature  doll  of  porcelain,  five 
eighths  of  an  inch  long  and  three  eighths  of  an  inch  wide,  was  found  firmly  wedged 
in  the  glottis,  whence  it  was  extracted  through  the  wound  without  diflSculty.     The 
wound  was  treated  openly,  and  the  child  recovered.     (See  Fig.  98.) 

2.  Laryngoflssure. — Fission  of  the  larynx  for  the  removal  of  tumors  or 
a  foreign  body  was  performed  three  times  by  the  author.  In  one  case  of 
recurrent  diffuse  papilloma  a  very  good  final  result  was  secured.     In  another 


lOi  RULES   OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 

one,  done  for  epithelioma,  speedy  relapse  followed.  In  the  third  case  the 
presence  of  a  foreign  body  and  inflammatory  granuloma  required  the  step. 
The  body  and  new-growth  were  removed,  but  the  perichondritic  inflamma- 
tion maintained  fora  very  long  time  such  an  intense  swelling  of  the  laryngeal 
mucous  membrane  that  the  tracheal  cannula  had  to  be  worn  until  June,  1887. 

Case  I. — Mrs.  0.  Lehmann,  twenty-four,  epithelioma  of  both  vocal  cords.  April  11, 
ISSJj,. — At  the  German  Hospital,  laryngofissure  and  extirpation  of  both  vocal  cords  and 
the  adjacent  mucous  membrane  were  done.  April  15th. — Cannula  removed.  April  30th. 
— Wound  healed.  Relapse  manifesting  itself  soon  afterward,  excision  of  the  larynx  was 
done  in  the  summer  of  the  same  year  by  Dr.  F.  Lange.  who  took  charge  of  the  service 
at  the  German  Hospital  after  the  expiration  of  the  author's  term. 

Case  II. — David  Popplewell,  machinist,  aged  forty-two;  recurrent  papilloma  of 
the  larynx,  that  had  been  treated  endolai'yngeally  by  Dr.  Gleitsmann,  who  kindly 
directed  the  patient  to  the  author.  July  9,  i555.—  Laryngo fission  at  the  German 
Hospital.  Removal  of  the  posterior  half  of  right  vocal  cord;  excision  of  several 
disseminated  papillomata  and  searing  of  their  base  by  the  thermo-cautery.  August 
5th. — External  wound  healed;  voice  much  improved. 

Case  III. — Julius  Meyer,  jieddler,  aged  thirty-nine ;  recurrent  stenosis  after  trache- 
otomy (see  case  on  page  103)  done,  December  18, 1886,  for  the  removal  of  a  foreign  body 
and  granuloma  from  the  larynx.  January  27.,  1887. — Laryngofissure.  Moderate  return 
of  the  new-growth  about  the  defect  of  the  mucous  membrane  in  which  the  end  of  the 
wooden  splinter  had  been  found  imbedded.  The  probe  was  introduced  into  this  aper- 
ture, and  penetrated  downward  and  backward  to  a  distance  of  three  fourths  of  an  inch, 
thin  pus  exuding  from  the  sinus.  Intense  swelling  and  hypersemia  of  tfie  entire  mucous 
membrane  and  submucous  tissue  were  noted.  Perichondritis  was  diagnosticated,  and  a 
tracheal  tube  was  left  inserted  in  the  wound.  The  patient  readily  recovered  from  the 
operation,  but  subsequently  could  not  get  along  without  a  cannula  till  June,  1887. 

To  prevent  the  entrance  of  blood  into  the  bronchi  the  author  tried  the 
use  of  a  tampon  cannula  in  each  one  of  the  preceding  cases.  It  had  to  be 
abandoned,  however,  as,  taking  up  too  much  space,  it  cramped  the  operator. 
It  was  found  quite  satisfactory  to  press  into  the  lower  angle  of  the  laryn- 
geal wound  a  small  sponge,  leaving  enough  space  below  it  for  the  admission 
of  air. 

3.  Extirpation  of  the  Larynx. — There  is  no  doubt  in  the  author's  mind 
that  partial  or  total  extirpation  of  the  larynx  for  malignant  new-growths,  if 
clone  early,  is  the  correct  treatment,  and  will  be  successful  in  direct  proportion 
to  the  readiness  and  thoroughness  with  which  it  is  done.  This  view  is  in  full 
accord  with  the  accepted  principles  of  the  treatment  of  malignant  neoplasms 
of  all  other  regions  of  the  body.  The  large  rate  of  mortality  recorded  so 
far  after  extirpation  of  this  organ  is  due  in  a  great  measure  to  the  fact,  that 
the  step  was  resorted  to  mostly  in  otherwise  hopeless  and  desperate  cases, 
in  which  endolaryngeal  therapy  had  utterly  failed  to  give  relief. 

The  earlier  the  operation  is  done  after  due  establishment  of  the  diagnosis, 
the  less  mutilating  it  need  bo.  Unilateral  extirpation  of  the  larynx  is  far 
less  dangerous  than  the  total  removal  of  the  organ,  and,  as  a  number  of  suc- 
cessful cases  testify,  even  a  fair  degree  of  phonation,  together  with  unim- 
paired deglutition,  may  be  preserved  by  it. 


SPECIAL  APPLICATION  OF  THE   ASEPTIC  METHOD.         105 

Case  I.* — Paul  ILilin,  barber,  iigcd  titty.  Novemher^  1870. — Increasing  dysphagia. 
Dr.  E.  Gruening  diagnosticated  an  elevated  ulcer  of  tlie  size  of  a  half-dollar  coin,  occupy- 
ing the  depression  bounded  by  tbe  right  side  of  the  base  of  the  epiglottis,  the  right  side 
of  tlie  base  of  the  tongue,  and  the  right  wall  of  the  pharynx,  a  site  corresponding  to 
that  of  the  glosso-epiglottic  and  aryteuo-epiglottic  folds,  and  more  particularly  to  that  of 
the  sinus  pyriformis.  The  mucous  covering  of  the  epiglottis  was  seen  to  be  tliickened 
and  congested.  The  cervical  glands  did  not  appear  to  be  affected.  No  evidence  of 
syphilis  could  be  elicited,  either  from  the  history  or  from  the  physical  examination  of  the 
patient,  excepting  a  moderate  degree  of  onychia,  characterized  by  roughening  of  the 
finger-nails.  In  the  course  of  the  treatment  it  became  evident,  however,  that  this  hitter 
trouble  was  due  only  to  the  fact  that,  in  pursuing  his  trade,  his  fingers  were  much  ex- 
posed to  the  action  of  soap-lather. 

Anti-syphilitic  treatment  was  lustituted  and  continued  for  some  time  with  apparent 
benefit,  the  patient  regaining  to  a  certain  extent  the  ability  to  swallow.  The  improve- 
ment was,  however,  merely  temporary ;  the  dysphagia  returned,  and  the  patient  soon 
began  to  suffer  from  the  inanition  thus  engendered. 

Preliminary  tracheotomy  was  performed  January  18,  1880,  at  the  German  Hospital. 
March  5,  1880. — Unilateral  exsection  of  the  larynx  was  done  with  the  able  assistance  of 
Drs.  Gruening,  Bopp,  Lefferts,  and  Dr.  Degner,  the  house-surgeon,  to  whom  great 
credit  is  due  for  the  skill  and  patience  exhibited  in  the  difiicult  and  tedious  after-man- 
agement of  tbe  case. 

An  incision  was  carried  from  tbe  median  line  of  the  byoid  bone  along  its  upper 
margin  outward  .to  the  extent  of  three  inches,  exposing  the  right  lingual  artery,  which 
was  ligated.  A  second  incision  was  carried  downward  from  tbe  starting-point  of  tbe 
first,  in  the  median  line,  to  the  opening  for  the  cannula,  exposing  the  anterior  surface  of 
the  hyoid  bone  and  larynx,  and  the  flap  thus  formed  was  dissected  up  with  all  the 
underlying  soft  parts  and  turned  outward.  Trendelenburg's  tampon-cannula  bad  been 
fitted  into  the  trachea.  Tbe  right  half  of  tbe  hyoid  bone  was  then  exsected,  a  double 
ligature  placed  around  tbe  superior  laryngeal  artery,  and  the  same  divided.  The  crico- 
thyroid ligament  was  cut  across,  a  pair  of  bone  scissors  inserted  into  tbe  larynx,  and 
the  thyroid  cartilage  divided  in  the  median  line.  Trendelenburg's  tampon  cannula  did 
not  fulfill  tbe  requirements  owing  to  a  leak  in  the  inflated  bladder,  so  that  blood  man- 
aged to  find  its  way  into  tbe  trachea.  An  attempt  to  make  it  serviceable  by  winding 
layers  of  moistened  gauze  around  the  cannula  was  unsuccessful,  and  during  the  rest  of 
the  operation  it  became  necessary  to  fill  out  the  lower  part  of  tbe  larynx  with  small 
sponges.  The  interior  of  the  larynx  was  now  exposed  and  showed  an  oval  tumor,  of 
about  the  size  of  a  pigeon's  egg,  situated  in  tbe  substance  of  tbe  right  false  vocal  cord, 
involving  the  posterior  half  of  the  true  vocal  cord  and  tbe  small  cartilages  belonging 
to  it.  The  right  half  of  the  thyroid  and  the  whole  of  the  arytenoid  cartilage  were 
now  dissected  up  and  removed,  together  with  the  whole  epiglottis.  The  pharynx  being 
thus  exposed  to  view,  its  entire  right  side  was  seen  to  be  diseased,  and  was  removed, 
together  with  tbe  right  tonsil  and  the  lower  half  of  the  right  pillars  of  the  palate.  Tbe 
base  of  tbe  tongue,  likewise  involved,  was  dissected  up  on  the  right  side  with  tbe 
scalpel,  on  the  left  with  the  tbermo-cautery.  Tbe  haemorrhage  was  insignificant,  and 
tbe  patient  rallied  promptly  after  tbe  operation. 

One  of  Tiemann's  excellent  soft-rubber  tubes  was  introduced  into  tbe  oesophagus, 
the  wound  thoroughly  cleansed  with  a  ten-per-cent  solution  of  zinc  chloride,  and  tbe 
whole  cavity  packed  with  moistened  balls  of  carbolized  cloth.  The  edges  of  the  hori- 
zontal incision  were  then  united  by  catgut  sutures. 

*  "  Archives  of  Laryngology,"  vol.  i,  No.  2,  June,  1880. 


106  RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 

The  oesophageal  tube  was  remarkably  well  tolerated,  and  the  patient's  nourishracRt 
was  satisfactorily  effected  through  it  during  the  whole  course  of  the  treatment. 

The  dressing  was  changed  once  every  twenty-four  hours. 

On  the  fifth  day  after  the  operation  the  patient  was  well  enough  to  sit  up  in  a 
chair  for  an  hour.  Three  days  later  he  could  ascend  a  flight  of  stairs  in  being  removed 
to  another  room,  and  a  week  later  he  spent  most  of  his  time  out  of  bed.  By  the  1st 
of  April,  twenty-six  days  after  the  operation,  he  took  a  walk  in  the  garden,  and  his 
weight  had  increased  by  Q^  pounds. 

The  large  cavity  contracted  rapidly,  and  finally  became  a  canal,  bounded  on  one 
side  by  the  remaining  half  of  the  larynx,  on  the  other  by  a  smooth  cicatrix  uniting  the 
skin  with  the  mucous  membrane  of  the  posterior  wall  of  the  pharynx. 

On  the  29th  of  April  the  patient  made  a  first  attempt  to  speak.  When  the  tracheal 
tube  was  closed,  he  could  converse  with  a  hoarse,  dull  voice,  quite  audible,  and  easily 
imderstood  at  a  distance  of  from  two  to  three  yards.  His  ability  to  swallow  has  in  a 
measure  been  recovered,  but  he  preferred  to  use  the  oesophageal  tube,  to  which  he  had 
become  accustomed.     By  the  5th  of  May  he  had  gained  14|  pounds  in  weight. 

The  patient  continued  well  until  February,  1881,  when  he  contracted  an  acute 
pleurisy,  to  which  he  succumbed  rather  suddenly  on  account  of  fatty  heart.  The  speci- 
men of  the  larynx  gained  at  the  post-mortem  examination  showed  absence  of  any  sign 
of  a  relapse. 

The  tumor  was  found  to  be  an  adeno-sarcoma. 

Case  II.* — Henry  O.,  porter,  aged  fifty-seven.  Rebellious  hoarseness  of  five 
months'  standing,  with  increasing  difiiculty  of  deglutition.  Marked  loss  of  flesh  and 
power.  March  16,  1885. — When  the  patient  was  directed  to  the  author  by  Dr.  S.  W. 
Gleitsraann,  a  deep-seated,  nearly  immovable,  hard,  glandular  swelling  of  the  size  of  a 
hen's  egg  was  noted  in  the  left  submaxillary  triangle.  Endolaryngeal  inspection 
revealed  the  presence  of  a  smootli,  pale  tumor,  the  size  of  an  almond,  commencing  in  the 
left  glosso-epiglottidian  fold  and  extending  through  the  substance  of  the  left  vocal 
cord  into  the  ary-epiglottidian  fold,  to  terminate  in  the  arytenoid  cartilage  with  a  knob- 
like protuberance.  March  18th. — Chloroform  being  administered,  the  diseased  glands 
were  removed.  The  sterno-mastoid  was  found  partly  involved,  and  this,  together 
with  a  piece  of  the  internal  jugular  vein  of  about  one  and  a  half  inch  in  length,  was 
removed  in  one  mass.  Then  inferior  tracheotomy  was  performed.  The  wound  healed 
kindly,  except  where  the  tracheal  tube  was  located,  and  April  27th,  under  chloroform, 
the  left  half  of  the  larynx  was  removed.  A  tampon  cannula,  made  by  George  Tiemann 
&  Co.  after  the  author's  directions,  was  inserted  and  suitably  distended  so  as  to  pre- 
vent the  entrance  of  blood  into  the  trachea.  After  this  an  incision,  commencing  at 
the  upper  notch  of  the  thyroid  cartilage  and  extending  to  the  lower  margin  of  the 
cricoid  cartilage,  laid  bare  the  larynx  in  the  median  line.  To  this  was  added  another 
incision,  commencing  in  the  upper  angle  of  the  flrst  cut  and  extending  horizontally  to 
the  anterior  margin  of  the  left  sterno-mastoid  muscle.  The  crico-thyroid  ligament  was 
split  to  admit  a  strong  pair  of  bone-pliers  for  the  division  of  the  thyroid  cartilage ;  but 
it  was  found  impossible  to  perform  this  act,  as  the  strongly  inclined  position  of  the 
cartilage  did  not  permit  an  effective  handling  of  the  instrument.  Therefore,  access 
was  gained  througli  an  incision  in  the  thyro-hyoid  ligament  from  above,  and  in  this 
manner  an  exact  division  of  the  calcified  cartilage  was  successfully  eff'ected.  After, 
this  the  epiglottis  was  cut  through  lengthwise,  the  left  half  of  the  crico-thyroid.  liga- 
ment was  divided,  and  the"  superior  thyroid  artery  was  included  in  a  double  ligature 
and  cut  through.  The  most  difficult  part  of  the  operation  consisted  of  the  dissection 
of  the  lateral  portions  of  the  larynx  and  pharynx,  closely  adherent  to  the  carotid  artery 

*  "  Annals  of  Surgery,"  .January,  1886,  p.  20. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        107 

by  cicatricial  tissue,  caused  by  the  extirpatioQ  of  the  submaxillary  glands.  Shallow 
incisions,  running  parallel  with  the  course  of  the  carotid  artery,  were  cautiously  made 
one  after  another,  and  the  difficult  task  seemed  almost  completed  when  suddenly  a 
powerful  jet  of  arterial  blood  welled  up  from  the  bottom  of  the  wound.  The  bleeding 
point  was  easily  secured  in  a  pair  of  artery  forceps,  and  then  it  was  ascertained  that 
the  trunk  of  the  superior  thyroid  artery  (doubly  ligated  further  below  prior  to  this) 
had  been  cut  away  on  a  level  with  its  inosculation  into  the  carotid.  A  catgut  liga- 
ture was  applied  around  the  main  trunk  above,  another  below  the  artery  forceps,  and 
when  the  instrument  was  removed  a  round  hole  in  the  side  of  the  carotid  became  visi- 
ble. The  remaining  adhesions,  corresponding  to  the  lateral  portion  of  the  pharynx  on 
the  left  side,  could  now  be  easily  dissected  out.  The  tampon  cannula  was  removed,  and 
it  was  found  that  no  blood  whatever  had  entered  the  trachea.  A  soft  tube  was  in- 
serted into  the  oesophagus,  the  wound  was  loosely  packed  with  iodoformed  gauze,  and 
an  ordinary  tracheal  cannula  was  left  in  the  lower  angle  of  the  tracheal  wound.  Finally, 
the  horizontal  incision  was  closed  by  a  number  of  catgut  sutures.  The  duration  of  the 
operation  was  one  hour  and  three  quarters — the  anaesthesia  throughout  undisturbed. 

Microscopical  examination  of  the  new-growth  by  Dr.  L.  Waldstein  gave  the  diag- 
nosis of  alveolar  sarcoma. 

The  subsequent  course  of  the  wound  was  very  satisfactory  and  free  from  fever  or 
suppuration,  the  patient's  only  complaint  being  a  rather  profuse  secretion  of  saliva. 
Nutrition  was  carried  on  by  the  oesophageal  tube,  the  patient  consuming  considerable 
quantities  of  milk,  eggs,  and  an  emulsion  composed  of  beef-tea  and  crushed  boiled  beef; 
finally,  a  generous  supply  of  good  whisky. 

From  May  10th  on,  the  oesophageal  sound  was  introduced  twice  daily  for  purposes 
of  nutrition.  On  May  13th  the  tracheal  cannula  was  abandoned.  On  the  same  day 
the  innermost  layers  of  the  iodoformed  gauze  packing  became  detached,  and  were 
replaced.  The  entire  wound  was  found  to  be  in  a  vigorous  process  of  granulation,  and 
was  considerably  contracted. 

May  15th. — The  patient  swallowed  a  small  quantity  of  coffee. 

May  27th. — Sutures  were  removed  ;  wound  firmly  united.  Increase  of  body  weight 
four  and  a  half  pounds.  May  31st. — Patient  was  discharged  cured  from  the  hospital, 
good  deglutition  being  noted.  June  12th. — Removal  of  a  small,  suspicious  gland  from 
the  left  supraclavicular  space.  March  13,  1886. — Removal  of  an  enlarged  lymphatic 
gland  from  left  suprahyoid  region.  Since  then  the  patient  remained  well,  attending 
to  his  laborious  occupation.  He  could  speak  with  a  very  audible  hoarse  intonation. 
The  right  vocal  cord  performed  its  function  normally.  In  March,  188V,  relapse 
appeared  in  the  cicatrix  about  the  insertion  of  the  stump  of  the  epiglottis,  for  which 
subhyoid  pharyngotomy  was  performed,  April  22,  1887,  at  the  German  Hospital.  A 
portion  of  the  cicatrix,  together  with  a  section  of  the  base  of  the  tongue,  was  removed. 
The  external  wound  was  united  by  three  rows  of  superimposed  catgut  sutures.  Deg- 
lutition was  hardly  disturbed  by  the  operation;  the  external  wound  healed  by  adhe- 
sion, and,  May  3d,  patient  was  discharged  cured. 

In  both  of  the  preceding  cases  decided  alleviation  of  the  patients' 
wretched  condition  and  an  undoubted  prolongation  of  life  were  achieved. 

IX.     GOITRE. 

The  aseptic  method  and  an  improved  technique  of  dissection  have 
materially  reduced  the  formidable  perils  of  the  surgical  treatment  of  goitre, 
justly  dreaded  by  old-time  practitioners. 


lOS  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

In  goitre  encroaching  upon  the  trachea,  the  question  must  be  iirst  de- 
cided whether  the  growth  is  cystic  or  parenchymatous.  If  cystic,  various 
forms  of  treatment  offer  a  fair  chance  of  cure.  The  cyst  can  be  tapped  and 
injected  with  tinctnre  of  iodine,  like  a  hydrocele  ;  or  it  can  be  exposed  by 
dissection,  incised,  and  its  walls  sutured  to  the  skin,  like  the  sac  in  hydro- 
cele operated  on  by  Volkmann's  method  (Schinzinger). 

Case. — Lena  Kaiser,  aged  thirty-five.  Cystic  goitre  of  the  thyroid  body.  It  was 
as  large  as  a  child's  fist,  and  the  source  of  much  discomfort  to  the  patient  on  account 
of  the  severe  dyspnoea  it  produced.  November  23^  1882. — At  the  German  Hospital, 
exposure  of  the  capsule  of  the  goitre.  A  plexus  of  much-distended  veins  was  included 
in  two  sets  of  double  mass  ligatures,  between  which  the  capsule  was  cut  into.  The 
parenchyma  of  the  gland  was  divided,  and  the  sac  of  the  cyst  being  exposed  was 
incised  and  attached  to  the  skin  by  two  continuous  sutures.  The  cavity  was  packed 
with  carbolized  gauze.     Decemher  22d. — Patient  was  discharged  cured. 

Where  the  presence  of  a  number  of  contiguous  cysts  is  made  out,  their 
enucleation  will  be  appropriate.  The  procedure  is  not  difficult,  and  offers 
the  additional  advantage  of  the  possibility  of  primary  union  and  a  speedy 
cure. 

Case. — Hannah  S.,  servant,  aged  thirty-one.  January  16,  1886. — At  Mount  Sinai 
Hospital,  extirpation  of  four  contiguous  cysts  of  the  thyroid  body.  Flap  incision;  the 
thyroid  capsule  was  cut  into  between  two  rows  of  mass  ligatures ;  after  this  the  cysts 
were  shelled  out  without  difficulty.  The  wound  was  drained  and  sutured.  Primary 
union.     Patient  was  discharged  cured  February  21st. 

Parenchymatous  goitre  may  be  treated  with  some  hope  of  success  by  the 
methodical  injection  of  tincture  of  iodine  in  cases  in  which  the  tumor  is 
soft  and  vascular.  Should  this  plan  fail,  or  when  the  tumor  is  very  dense 
and  hard,  excision  must  be  performed. 

Total  removal  of  the  thyroid  gland  is  apt  to  produce  a  deep  alteration  of 
the  general  condition  denoted  '' myxmdema,''''  or  ^'cachexia  strumipriva" 
(Kocher),  characterized  by  idiotism,  loss  of  sexual  power,  and  general  dense 
edematous  infiltration  of  the  subcutaneous  connective  tissue  ending  in  death. 
Hence,  a  portion  of  the  glandular  tissue  ought  to  be  always  left  behind  to 
perform  its  function,  so  necessary  to  the  healthy  state  of  the  nervous  system. 

The  principles  laid  down  for  the  safe  removal  of  tumors  (page  50)  should 
guide  the  surgeon  in  exsecting  thyroid  swellings.  Hsemorrhage  from  the 
large  veins  of  the  capsule  is  to  be  avoided  by  the  timely  use  of  Thiersch's 
spindles  and  of  double  ligatures.  Dissection  should  be  systematic  and  de- 
liberate, and  especial  care  should  be  devoted  to  the  preservation  of  the  re- 
current laryngeal  nerve,  which  will  be  found  behind  the  lateral  lobe  of  the 
thyroid  gland  in  the  groove  separating  the  trachea  from  the  oesophagus. 

Case. — Rosa  Rosenfeld,  cook,  aged  twenty-four.  Parenchymatous  hyperplastic 
goitre  of  the  body  and  right  thyroid  lobe,  causing  severe  dyspnoea.  October  9,  1884- — 
At  Mount  Sinai  Hospital,  extirpation  of  the  right  lobe  and  body  of  the  gland  from  a 
spacious  flap  incision.  A  pedicle  was  formed  toward  the  left  lobe,  and,  being  first  liga- 
tured, was  cut  off.  In  dissecting  up  the  right  lobe,  which  was  found  to  be  insinuated 
between  the  trachea  and  oesophagus,  the  recurrent  laryngeal  nerve  was  separated  and 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.         l(i<> 

drawn  aside.  Drainage,  suture,  and  aseptic  dressings.  The  wound  healed,  witli  the 
exception  of  the  drainage-tracks  under  the  first  dressing,  which  was  changed  on  Octo- 
ber 19th  Some  hoarseness  due  to  paresis  of  the  right  vocal  cord  persisted  for  five 
months,  but  ultimately  disappeared. 

Tracheotomy  for  goitre  is  one  of  the  most  formidable  tasks  the  surgeon 
may  be  called  upon  to  perform.  It  was  twice  the  author's  duty  to  under- 
take this  procedure  for  extreme  dyspnoea  caused  by  malignant  tumor  of  the 
thyroid  gland.  One  case  was  complicated  by  mitral  insufficiency  and  acute 
broncho-pneumonia,  and  ended  fatally.  In  the  other  one  the  sujDra-sternal 
portion  of  a  very  large  fibro-sarcoma  of  the  thyroid  gland  had  to  be  first 
extirpated  before  access  could  be  had  to  the  trachea.  This  case  also  ended 
lethally. 

Case  I. — Rosa  Guttmann,  widow,  aged  thirty-six.  Large  and  growing  originally 
parenchymatous,  later  sarcomatous,  substernal  goitre  of  five  years'  standing.  Mitral  in- 
sufiiciency  and  severe  acute  broncho-pneumonia.  Dr.  S.  Kohn,  who  referred  the  patient 
to  the  author,  diagnosticated  paralysis  of  the  right  vocal  cord.  November  11,  1879. — 
Patient  was  admitted  to  German  Hospital  in  a  very  exhausted  condition.  After  copious 
stimulation  tracheotomy  was  performed.  Only  a  very  small  amount  of  ether  was  admin- 
istered for  the  cutaneous  Incision.  Division  of  the  goitre  by  the  therrao-cautery  was 
tried,  but  had  to  he  given  up  on  account  of  the  slowness  of  the  process  and  the  great 
hfemorrhage  from  the  enormously  distended  veins.  The  expedient  of  at  once  taking 
up  and  firmly  retracting  the  divided  tissues  by  large,  four-pronged,  sharp  hooks,  proved 
more  efficacious  in  checking  haemorrhage.  With  a  few  rapid  strokes  the  trachea  was 
exposed  and  opened,  and,  a  large-sized  soft  catheter  being  introduced,  respiration  be- 
came well  established.     But  a  few  minutes  afterward  patient  expired. 

Case  II. — Elizabeth  K.,  aged  sixty-two.  A  very  fat  woman,  with  a  small  pulse, 
suffering  from  extreme  dyspnoea  due  to  the  presence  of  a  very  large  and  hard  supra- 
and  infra-sternal  fibro-sarcomatous  goitre.  August  23,  1882. — Extirpation  of  the 
supra-sternal  part  of  the  swelling  with  subsequent  tracheotomy,  for  which  a  specially 
constructed  cannula  with  a  long  tube  was  used.  Relief  of  dyspnoea.  Copious  stimula- 
tion was  employed  by  the  family  attendant  to  such  an  extent  that  in  the  night  of 
August  24th  the  patient  became  boisterously  drunk,  and  died  in  a  soporous  condition 
under  the  symptoms  of  acute  alcoholism. 

X.     AMPUTATION    OF    THE    BREAST. 

In  preantiseptic  practice  the  rate  of  mortality  observed  after  amputa- 
tion of  the  breast,  mainly  due  to  accidental  wound  comjjlications,  was  nearly 
as  high  as  that  of  major  amputation  of  the  limbs. 

The  notable  depression  of  the  death-rate  that  has  taken  place  since  is 
directly  due  to  cleanlier  methods. 

The  absence  of  a  proportionate  decrease  of  the  death-rate,  caused  by  re- 
lapse of  the  malignant  growths  for  which  the  operation  is  performed,  is  to 
be  attributed  to  the  tardiness  of  the  general  practitioner  in  advising  and 
urging  early  removal,  and  the  unwillingness  of  the  patients  to  heed  timely 
advice. 

In  view  of  the  fact  that  over  ninety  per  cent  of  all  mammary  tumors 
are  carcinomatous,  the  benefit  of  the  doubt  belongs  to  the  view  which  urges 
Ifi 


110 


RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 


to  removal.  ^1  probatory  incision  at  least  slumld  he  insisted  on  in  every 
case  of  solid  chronic  intumescence  of  the  breast  that  remains  uninfluenced 
by  proper  local  and  general  treatment  directed  against  syphilis  or  chronic 
infam  mat  org  mastitis. 

Particd  operations  are  admissible  only  where  the  youth  of  the  patients, 
the  smoothness  and  mobility  and  slow  progress  of  the  tumor  justify  the 
assumption  of  a  benign  growth,  such  as  adenoma  or  adeno-fibroma,  or 
where  probatory  puncture  leaves  no  doubt  of  the  presence  of  a  simple  re- 
tention cyst. 

In  these  cases  the  operation  proposed  by  T.  G.  Thomas  is  very  appro- 
priate, and  gives  satisfactory  results  both  as  to  the  completeness  of  the  re- 
moval and  the  cosmetic  effect.  The  incision  is  laid  in  the  pectoro-mammal 
fold,  and  the  breast-gland  is  raised  from  the  pectoral  fascia  sufficiently  to 
enable  the  surgeon  to  incise  it  on  its  posterior  aspect.  After  the  enucleation 
of  the  tumor  the  breast  is  replaced,  and,  the  wound  being  drained,  the 
skin  is  united  by  an  exact  suture.  The  cicatrix  remains  hidden  under 
the  overlapping  breast. 

Case  T. — Miss  C.  L.,  governess,  aged  twenty.  Adenoma  of  left  breast  of  the  size 
of  a  hen's  egg.     December  12,  1884.- — At  Mount  Sinai  Hospital,  Thomas's  operation. 

December  22d. — First 
cliange  of  dressings. 
December  SJfth. — Dis- 
charged cured.  De- 
cember 12,  1886.— No 
relapse  ;  very  fine  lin- 
ear cicatrix. 

Case  II.  —  Miss 
Tillie  G.,  aged  six- 
teen. Adeno-fibroma 
of  left  breast  of  the 
size  of  a  small  apple. 


Fio.  ;»;».— i  1 


laiiiuiary  ulaml   Ix'iuir  tli-tac'liud  from  below,  the  surgeon  inserts  liis  left  liaud 
under  tlic  hreiist  to  complete  the  upper  section. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.         HI 


Decemher  SO,  ISSG. — Tliomas's  operation  at  Mount  Sinai  Hospital.     December  30th. — 
Dressings  changed.     January  4,  ISSl. — Wound  firmly  united. 

Whenever  amputation  of  tlie  breast  is  performed  for  malignant  tumor, 
the  operation  must  he  radical,  or  at  least  as  radical  as  possible.  No  regard 
wliatever  sliould  be  paid  to  cosmetic  considerations,  the  object  of  the  measure 
being  the  extirpation  of  a  deadly  disease,  which,  if  not  eliminated,  is  sure 
io  till.  A  wide  berth  should  be  given  to  the  visible  limits  of  the  disease, 
and  the  knife  should  take  away  at  least  an  inch  and  a  half  of  apparently 
healthy  skin.  The  axillary  fat  and  glands  must  be  invariably  removed  in 
mass,  whether  intumescence  is  to  be  felt  or  not. 

If  the  axillary  vein  be  attached  to  degenerated  lymphatic  glands,  the 
attached  segment  must  be  included  in  two  ligatures,  and  the  intervening 
piece  cut  out  together  with  the  adherent  mass. 

The  technique  of  breast  amputation  is  simple.  After  marking  by  a 
shallow  cut  the  extent  of  the  two  semi-elliptic  incisions  that  should  include 

the  part  to  be  removed,  the  infe- 
rior margin  of  the  breast-gland  is 
exposed.  The  pectoral  fascia  be- 
ing incised,  the  mamma  is  gradu- 
ally dissected  up  from  the  thorax 
till  its  upper  limit  is  reached. 
The  surgeon's  hand  is  slipped  in 
under  the  breast,  and  the  upper 
incision  completes  its  detachment, 
except  where  the  lym- 
phatic vessels,  pass- 
ing along  the  pecto- 
ral fold  from  the 
breast  to  the  arm- 
pit, form  a  sort  of  a 
pedicle.  The  bleed- 
ing vessels  are  secured 
as  they  are  cut,  and 
the  pectoral  wound  is 
covered  with  a  towel 
wrung  out  of  corros- 
ive-sublimate lotion, 
to  remaiii  under  its  protection  during  the  removal  of  the  axillary  contents. 
The  incision  is  extended  well  up  the  arm  into  the  axilla,  and  the  skin  is  dis- 
sected up  for  about  an  inch  to  each  side  of  the  cut.  The  fascia  is  divided 
where  the  incision  can  be  made  boldly  upon  the  edge  of  the  pectoral  muscle 
anteriorly,  and  the  latissimus  dorsi  posteriorly.  Proceeding  from  this  latter 
incision,  the  loose  connective  tissue  is  divided  by  blunt  dissection  with  a 
thumb-forceps  and  the  handle  of  the  scalpel,  until  the  axillary  vein  is 
exposed  to  view.  With  this  the  most  important  step  of  the  operation  is 
accomplished.     Seeing  the  vein  will  prevent  its  accidental  injury,  and  from 


Fig.  100. — Eeraoval  of  axillary  contents.     The  surgeon  holdini;; 
the  detached  breast  serving  as  a  handle. 


112  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

this  on,  in  most  cases,  dissection  will  be  directed  mu  ay  from  instead  of  toward 
the  vein.    The  loose  fat  can  be  easily  detached  from  all  its  lateral  adhesions. 


Fig.  101. — Sutured  wound  after  amputation  of  breast.      Counter-incision  through  latissimus  for 

purposes  of  drainage. 

The  vessels  and  nerves  which  traverse  the  adipose  tissues  can  be  distinctly- 
felt  and  seen  as  they  are  successively  approached.  If  necessary  the  long 
thoracic  artery  and  vein,  and  sometimes  the  subscapular  vessels,  should  be 


Fio.  102. — Completed  dressing  after  breast  amputation. 

taken  up  and  cut  between  two  forceps.  The  nerves  ought  to  be  preserved. 
During  the  dissection  of  the  axillary  contents,  the  breast  serves  as  a  suitable 
handle.  Breast  and  axillary  contents  are  removed  in  one  mass.  Thus  the 
intervening  lymphatic  ducts  are  certainly  taken  away  together  with  the 


SPECIAL  APPLICATION  OP  THE  ASEPTIC  METHOD.  118 

mammary  gland  and  the  axillary  lymphatic  gland.s.  After  due  irrigation, 
a  counter-incision  is  made  on  the  external  aspect  of  the  latissimus-dorsi 
muscle.  The  knife  should  divide  the  skin  and  fascia  only  ;  then  a  dressing- 
forceps  is  thrust  through  the  muscle  into  the  most  dependent  part  of  the 
axillary  wound,  when  it  is  made  to  grasp  the  end  of  a  stout  drainage-tube, 
which  is  drawn  out  through  the  counter-incision,  to  be  transfixed  with  a 
safety-pin  and  clipped  off  even  with  the  skin. 

After  this  the  pectoral  wound  is  united.  Lister's  button  suture,  or  a 
quilled  suture,  or  any  other  of  the  known  forms  of  retentive  suture,  is 
applied  to  relieve  tension.  After  another  irrigation,  the  fine  catgut  sutures 
of  coaptation  are  put  in  until  the  wound  is  closed.  The  wound  is  once 
more  flushed  out  with  mercuric  lotion,  and  is  covered  with  the  dressings, 
care  being  taken  to  make  them  the  thickest  about  where  the  drainage-tube 
issues  forth.  The  dressings  are  secured  by  roller-bandages,  and  the  arm  is 
either  included  in  the  turns  of  the  bandage,  the  uhia  first  being  well  joadded, 
or,  being  left  out,  is  supported  by  an  extra  sling. 

Ordinarily,  the  dressings  are  changed  and  the  tube  is  removed  on .  the 
tenth  day  after  the  operation,  when  the  retention  sutures  are  also  extracted 
should  they  not  have  been  absorbed  by  this  time.  A  smaller  dressing  secures 
the  parts  against  injury.  Five  days  later  another  change  of  dressings  may 
take  place,  wlren  the  drainage  opening  will  be  found  closed  by  a  plug  of 
granulations.  After  this  a  covering  of  cerate  or  lead  plaster,  with  a  little 
pad  of  cotton  secured  by  a  strip  of  adhesive  plaster,  will  be  all  that  is  neces- 
sary until  cicatrization  is  complete. 

It  is  remarkable  how  soon  the  arm  regains  its  power  of  abduction  in  cases 
that  remain  free  from  suppuration. 

Of  fifty  operations  for  tumors  of  the  mammary  gland,  forty-eight  were 
done  on  women  mostly  past  middle  life  ;  two  were  performed  on  men.  The 
male  cases  were  as  follows  : 

Case  I.— A.  B.,  aged  seventeen.  Growing  adenoma  of  right  mammary  gland. 
August  4,  1883. — Extirpation  of  the  tumor ;  axilla  was  not  interfered  with.  Uninter- 
rupted primary  union. 

Case  11, — George  Eckert,  blacksmith,  aged  sixty.  Large,  very  hard  epithelioma 
of  the  right  mammary  gland,  starting  from  the  nipple,  which  was  unrecognizable  in 
the  ulcerated  mass.  Axillary  glands  inV^olved.  AjjtU  27,  1886. — Amputation  of  breast 
and  evacuation  of  axilla  at  the  German  Hospital.  Large  portions  of  skin  and  of  the 
pectoralis  major  and  minor  muscles  had  to  be  removed.  Primary  union  followed, 
except  where  the  skin  could  not  be  brought  together.     June  Ith. — Discharged  cured. 

In  two  cases  of  adenoma  of  young  girls,  the  tumor  alone  was  removed. 

In  fiye  instances  (Mary  Hauser,  adeno-cystoma  ;  Emma  Bockhold,  cysto- 
sarcoma ;  Albert  Baron,  adenoma;  Sarah  S.,  cysto-adeno-fibroma ;  Frida 
Meissner,  adeno-fibroma),  the  mammary  gland  alone  was  amputated,  the 
axillary  space  remaining  intact. 

The  remaining  forty-three  cases  consisted  of  thirty-eight  cancers  and  five 
sarcomata.  In  each  of  these  the  entire  breast  and  all  the  axillary  contents 
were  removed. 


lli  EULES   OP  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Cancer 38  cases 

Sarcoma ti     " 

Adenoma 3     " 

Adeno-fibroma 2     " 

Adeno-cystoma 1  case 

Total 50  cases 

Of  this  number,  forty-one  times  healing  hy  primary  union  was  observed. 
Five  cases  suppurated  in  consequence  of  infection  of  one  or  another  kind 
at  the  time  of  the  operation  ;  three  cases  healed  by  granulation,  as  it  was 
impossible  to  cover  the  defect  caused  by  the  operation.  A  fourth  granulat- 
ing case  died  of  erysipelas,  contracted  outside  of  the  author's  care  (Julie 
Schmalz,  scirrhus)  while  the  wound  was  not  yet  healed. 

Of  the  cases  healed  by  primary  adhesion,  one  died  of  continuous  throm- 
bosis of  the  axillary  and  innominate  vein,  with  subsequent  embolism  of  the 
pulmonary  artery.  The  sudden  change  took  place  shortl}'^  after  the  first 
change  of  dressings,  made  eight  days  after  the  operation. 

Case. — Clara  Halm,  spinster,  aged  tliirty-two.  Novernber  SO,  1883. — Amputation 
of  left  breast,  with  evacuation  of  axilla  for  small-celled  adeno-carcinoina;  suture;  no 
drainage.  Deceraber  IJ^tTi. — First  change  of  dressings;  entire  wound  absolutely  healed. 
On  Christmas  eve  the  patient  was  selling  crockery  over  the  counter.  April  4,  1885. — 
Typical  amputation  of  right  breast  at  the  German  Hospital  for  the  same  affection, 
together  with  excision  of  relapsing  cancer  in  the  shape  of  a  small  node  in  the  cicatrix 
of  the  left  side.  Patient  was  doing  excellently  till  April  12th,  when  the  first  dressings 
were  changed,  and  the  wound  was  found  faultlessly  healed.  Immediately  after  the 
dressings  were  completed,  the  patient  became  faint  and  cyanosed;  breathing  labored, 
pulse  scarcely  to  be  felt ;  the  left  deep  Jugular  vein  was  permanently  distended. 
Hydropericardium  and  hydrothorax  developed  with  oedema  of  both  arms,  and  the 
patient  died  April  20th,  sixteen  days  after  the  operation,  having  had  normal  and  later 
subnormal  temperatures  throughout.  Autopsy  revealed  continuous  thromiosis  of  left 
axillary  and  anonyma  vein,  the  thrombus  extending  into  the  right  auricle  and  the 
pulmonary  artery ;  bilateral  hydrothorax,  hydropericardium,  and  a  hsemorrhagic  in- 
farction of  the  connective  tissue  in  the  posterior  mediastinum. 

The  only  unusual  circumstance  that  attracted  the  author's  attention 
immediately  before  the  second  and  fatal  operation  was  the  fact  that,  a  hypo- 
dermic injection  of  morphia  being  administered,  extensive  ecchymosis  ap- 
peared shortly  afterward  at  the  site  of  the  injection,  suggesting  a  morbid 
alteration  of  the  patient's  vascular  system. 

Thrombosis  and  embolism  were  observed  in  another  case,  which,  how- 
ever, ended  in  cure. 

Case. — Mary  Lier,  school-teacher,  aged  fifty-seven.  Suffering  from  old  pulmonary 
emphysema  and  chronic  bronchitis.  Face  slightly  cyanosed.  Scirrhus  of  right  breast; 
nipple  retracted,  discharging  dark,  tar-like  serum.  Novemher  IJf.^  1575. —With  the  kind 
assistance  of  Dr.  F.  Lange,  amputation  of  right  breast  and  evacuation  of  the  axilla  were 
fjerformed.  Anaesthesia  by  ether  was  very  bad.  Feverless  course  of  healing.  Novem- 
ber 19th. — Drainage-tube  was  removed.  November  23(1. — Apoplectiform  seizure,  fol- 
lowed by  aphasia  and  agraphy,  which,  however,  gradually  disappeared.  December 
20th. — The  wound  was  entirely  healed,  and  patient  could  again  speak  Bohemian,  her 


SPECIAL  APPLICATION   OP  THE   ASEPTIC   METHOD.         115 

motlier  tougue.     Gradually  she  reg'aincd  lier  German  and  English,  and  in  1882  author 
heard  from  her  as  being  able  to  write  again. 

One  of  the  sui)purating  cases  died  of  acute  catarrlial  pneumonia  and 
carcinosis  of  the  lungs,  twenty-two  days  after  the  operation,  the  wound 
doing  well  at  the  time  under  process  of  granulation. 

Case. — Mary  Volkmer,  housewife,  aged  forty-seven.  Soft  adeno-cancer  of  both 
breasts,  the  large  tumor  of  the  left  mamma  causing  much  distress.  March  17,  1881. — 
At  the  German  Hospital  amputation  of  left  breast  and  evacuation  of  the  axilla  were 
done.  "Wound  was  united  in  part  only  on  account  of  extensive  loss  of  integument. 
Suppuration  of  axillary  space  followed,  but  the  fever  resulting  therefrom  subsided 
directly  after  drainage  was  re-established.  Nevertheless,  patient  appeared  to  be  very 
ill.  April  8th. — Catarrhal  pneumonia  set  in,  to  which  she  succumbed.  April  9th. — 
On  post-mortem  examination  general  carcinosis  of  lungs  and  liver  and  catarrhal 
pneumonia  were  found. 

In  computing  the  three  fatal  cases,  that  of  Julie  Schmalz,  who  died  of 
erysipelas  contracted  under  the  care  of  another  physician  before  perfect 
cicatrization  had  taken  place,  can  Justly  be  excluded.  Accordingly,  of  the 
remaining  forty-nine  cases,  two  died  directly  in  consequence  of  the  opera- 
tion, none,  however,  on  account  of  septic  processes  established  in  the  wound. 
Thus,  the  author's  rate  of  mortality  from  accidental  wound  infection  in 
amputation  of-  the  breast  would  be  0  ;  from  other  causes  beyond  the  in- 
fluence of  the  surgeon,  a  trifle  more  than  four  per  cent  (4*08). 

XI.     ABDOMINAL    OPERATIONS. 

1.   General  Remarhs. 

The  relation  of  aseptics  to  the  surgical  treatment  of  the  peritoneal  cavity 
is  in  some  quarters  a  subject  of  hot  controversy  to  this  day.  On  one  side 
we  see  the  advocates  of  a  more  or  less  complicated  antiseptic  apparatus, 
including  the  spray,  achieving  very  good  results,  and  basing  success  upon 
the  strict  enforcement  of  their  cautelse.  But,  on  the  other  hand,  we  notice 
a  most  successful  laparotomist  maintaining  that  antiseptics  are  unnecessary, 
or  even  harmful,  and  that  he  is  accustomed  to  flush  the  peritoneal  cavity 
with  "water  from  the  tap,"  teeming  with  millions  of  bacteria,  and  yet  his 
results  vie  with  those  of  the  most  scrupulous  Listerian. 

Both  sides  to  the  controversy  have  abundant  and  incontrovertible  facts 
to  support  their  positions,  and  the  contradiction  seems  to  be  hopelessly  in- 
surmountable. It  certainly  is  extremely  bewildering  to  the  student  and 
beginner. 

Yet  this  contradiction  is  unreal,  and  let  us  say,  on  one  side,  also  disin- 
genuous. 

The  physiological  peculiarities  of  the  peritonseum,  most  notably  its  enor- 
mous absorbent  power,  endow  it  with  the  quality  of  neutralizing  the  deleteri- 
ous effects  of  limited  quantities  of  pyogenic  or  septic  micro-organisms,  a 
quality  not  possessed  to  such  an  extent  by  any  other  part  of  the  human 
organism. 


116  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGEEY. 

Grawitz  *  has  bi'onght  experimental  proof  of  the  fact  that  the  normal 
peritonaeum  will  at  once  absorb  into  the  circulation  moderate  quantities  of 
active  pyogenic  cocci,  where  they  will  be  widely  scattered  through  the  blood 
and  perish. 

Note. — This  fact  goes  very  far  to  explain  Lawson  Tait's  position,  who,  however,  althougli 
disclaiming  antiseptics,  devotes  most  scrupulous  care  to  asepticism — that  is,  to  the  cleansing  of 
hands  and  instruments.  His  instruments  are  few,  and  selected  with  a  view  to  simplicity.  His 
sponges  are  put  into  carbolic  hfio7i  for  disinfection.  The  water  used  for  the  immersion  of  his 
insti'uments  is  sterilized  by  boiling.  Most  of  the  bacteria  contained  in  his  ''  water  from  the 
tap  "  are  innocuous — that  is,  non-pyogenic ;  and  those  that  have  the  power  to  cause  suppuration 
are  too  few  to  produce  serious  trouble.  They  are  simply  absorbed  and  killed  off  by  the  great 
germicide,  the  blood. 

The  limit  of  the  quantity  of  pyogenic  cocci  required  to  produce  acute 
purulent  peritonitis  varies  with  the  size  and  state  of  health  of  the  animal 
used  in  the  experiment.  A  large  dog's  peritonaeum  would  resist  a  much 
greater  quantity  of  infectious  pus  than  that  of  a  small  dog  or  rabbit.  And 
a  healthy  animal  would  neutralize  more  septic  material  than  a  debilitated 
one  of  the  same  kind  and  weight. 

The  presence  in  the  peritoneal  cavity  of  a  larger  quantity  of  stagnant 
bloody  serum  than  can  be  readily  absorbed  within  an  hour,  will  suffice  to 
produce  purulent  peritonitis  on  the  addition  of  a  very  small  number  of 
cocci. 

If  the  fluid  is  absorbed  or  artificially  removed  by  drainage  before  the 
cocci  have  a  chance  to  vastly  multiply,  no  peritonitis  or  only  adhesive  forms 
of  the  inflammation  will  develop. 

Therefore,  it  is  rational  to  employ  drainage  in  cases  where  large  surfaces, 
denuded  of  peritoneum,  have  to  be  left  behind  in  the  abdomen. 

Denudation  of  the  surface  layer  of  the  peritoneal  endothelium  by  caloric, 
or  mechanical  or  chemical  influences,  is  also  conducive  to  the  development  of 
purulent  peritonitis.  It  favors  exudation  of  serum,  and  diminishes  or  de- 
stroys the  power  of  absorption  inherent  to  the  normal  peritonaeum.  Should 
even  a  minute  quantity  of  pyogenic  cocci  be  introduced  into  the  peritoneal 
cavity  under  these  circumstances,  purulent  peritonitis  may  readily  develop. 

The  practical  conclusions  to  be  drawn  from  the  preceding  facts  are  as 
follows  : 

1.  Although  the  normal  peritonaeum  will  tolerate  a  greater  quantity  of 
infectious  material  than  most  surgical  wounds,  yet  all  precautions  regarding 
the  cleansing  of  hands,  instruments,  sponges,  and  other  apparatus  used  for 
laparotomy  should  be  employed,  as  septic  infection  of  the  peritonaBum  is 
much  easier  to  prevent  than  to  cure. 

2.  Unnecessary  denudation  of  the  upjiermost  layer  of  the  peritonaeum 
should  be  avoided  as  much  as  possible. 

3.  Corrosive  solutions,  as,  for  instance,  of  carbolic  acid  or  mercuric  bi- 
chloride, are  not  to  be  used  on  the  peritonaeum.  As  soon  as  the  peritoneal 
cavity  is  opened,  Thiersch's  solution  should  be  employed  for  rinsing  the 

*  "  Charite  Annalen,"  xi.  Jalirg.,  page  770. 


SPECIAL  APPLICATION   OF  THE   ASEPTIC  METHOD.        117 

surgeon's    hands,    immersing    tlie    instruments,    sponges,    towels,    and,    if 
necessary,  for  irrigation. 

4.  A  careful  toilet,  that  is,  removal  of  all  exuded  serum  or  blood,  should 
precede  closure  of  the  abdominal  wound. 

5,  Where  large  denuded  surfaces  have  to  be  left  behind,  and  a  good  deal 
of  oozing  is  to  be  expected,  drainage  must  be  employed. 

NoTK. — If  the  drain-tube  is  brought  out  from  a  dependent  part  of  the  peritoneal  cavity, 
as,  for  instance,  through  DougUis's  cul-de-sac,  the  secretions  will  escape  spontaneously  by  the 
operation  of  the  law  of  gravity.  Whenever  the  drainage-tube  is  brought  out  above  the  symphysis, 
the  scrum  collecting  at  the  bottom  of  the  cavity  must  be  removed  either  by  hourly  mopping  out 
with  a  stick,  armed  with  a  pad  of  absorbent  borated  cotton,  or  by  exhausting  with  a  long-nozzled 
syringe,  introduced  to  the  bottom  through  the  hollow  of  the  drain-tube. 

G.  Should  it  become  evident  that  the  mode  of  drainage  employed  is  in- 
sufficient to  remove  a  copious  gathering  of  secretions,  febrile  symptoms, 
tenderness,  and  tympanites  developing  on  the  first  few  days  after  the  opera- 
tion, a  saline  purge  may  be  employed  in  preference  to  the  accustomed 
opium  treatment  (Tait).  Its  object  would  be  to  favor  rapid  absorption  of 
the  effused  serum  in  an  analogous  manner  seen  with  the  administration  of 
cathartics  for  the  rapid  removal  of  hydropic  accumulations  from  the  abdomi- 
nal cavity. 

7.  If  purulent  peritonitis  be  undoubtedly  established,  reopening  and 
irrigation  of  the  peritoneal  cavity  with  a  hot  1  :  5,000  solution  of  corrosive 
sublimate  may  be  taken  into  consideration,  provided  that  the  patient's  gen- 
eral condition  should  warrant  such  a  procedure. 

2.  Hernioto7ny, 

In  the  main,  the  success  of  herniotomy  depends  upon  the  condition 
of  the  strangulated  gut  at  the  time  of  the  oj)eration.  With  aseptic  pre- 
cautions, as  long  as  the  gut  is  not  necrosed,  herniotomy  is  fraught  with 
very  little  danger.  From  the  moment  that  intestinal  gangrene  has  set  in, 
the  preservation  of  asepticism  becomes  extremely  difficult.  Contact  alone 
with  the  decayed  gut  is  infectious.  Laceration  of  the  friable  intestinal  wall 
is  very  likely  to  occur  on  employment  of  the  least  amount  of  force,  and 
usually  leads  to  further  contamination  by  escaping  intestinal  contents. 

In  addition  to  this,  the  general  condition  of  patients  with  intestinal 
necrosis  is  mostly  wretched.  Systemic  intoxication,  and  the  tendency  to 
heart-failure  induced  by  constant  vomiting,  vastly  increase  the  perils  of 
anaesthesia  and  haemorrhage,  and  the  prognosis  is  thereby  rendered  all  the 
more  doubtful. 

The  free  exhibition  of  anodynes,  especially  in  the  shape  of  hypodermic 
injections  in  the  presence  of  strangulated  hernia,  is  very  often  followed  by 
fatal  consequences.  The  most  acute  symptoms  are  blurred  or  blotted  out 
entirely,  and  a  false  sense  of  security  is  apt  to  lull  the  apprehensions,  and 
to  betray  patient  and  physician  into  undue  procrastination. 

Out  of  the  thirty-one  cases  of  herniotomy  performed  by  the  author  both 
for  strangulation  and  for  the  radical  cure  of  the  complaint,  eight  died. 
IT 


118  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Sis  out  of  this  number  exhibited  necrosis  of  the  gut,  and  all  of  these  died. 
Of  the  remaining  two,  one,  whose  gut  was  sound,  died  of  acute  nephritis, 
presumably  due  to  the  use  of  ether  as  an  angestbetic  ;  the  other  one  of 
general  tuberculosis  of  the  peritonaeum. 

Case  I. — A.  Schlesinger,  aged  seventy-three,  strangulated  left  inguinal  hernia  of 
twenty-four  hours'  standing.  Ap?-il  IS,  1885. — At  Mount  Sinai  Hospital,  the  hernial  sac 
was  exposed  under  ether  anfesthesia,  A  knuckle  of  gut  could  be  felt  within  the  sac,  con- 
taining a  cubic,  friable  body  that  was  easily  crusheJ,  whereupon  the  gut  was  replaced 
in  the  abdominal  cavity  without  any  difficulty.  The  wound  was  sutured  and  dressed. 
Duration  of  the  operation,  twenty  minutes.  The  wound  healed  by  primary  adhesion, 
but  ursemic  symptoms,  with  suppression  of  the  renal  secretion  and  vomiting,  developed 
on  tlie  second  day.  The  scanty  urine  was  found  contaiuing  blood  and  a  large  amount 
of  albumen.     April  22cl. — The  patient  died  in  uremic  coma. 

Inquiry  elicited  the  fact  that,  preceding  the  day  of  the  patient's  illness, 
he  had  largely  consumed  of  a  dish  of  potato  soup.  The  toothless  old  man 
had  bolted  some  of  the  potato,  a  piece  of  which  having  made  its  way  into 
the  hernia  caused  strangulation. 

The  other  fatal  case,  not  due  to  necrosis  of  the  gut,  was  as  follows  : 

Case  II. — Mrs.  Henrietta  Bolz,  housewife,  aged  sixty,  an  ill-nourished,  emaciated 
person,  who  said  that  she  had  been  suffering  from  belly-ache  and  constipation  for  two 
months,  and  that  she  has  had  severe  and  continuous  fever  that  caused  her  present 
emaciation.  She  also  noted  that  she  had  lost  most  of  her  hair.  Forty-eight  hours  pre- 
vious to  her  admission,  irreducible  femoral  hernia  of  the  right  side  was  diagnosticated 
by  a  medical  man.  Vomiting,  no  fever,  and  great  tenderness  over  the  abdomen  were 
found,  and  it  was  deemed  proper  to  explore  the  hernia.  Accordingly  the  operation 
was  done,  May  7,  1887,  at  the  German  Hospital,  xifter  incision  of  the  sac,  this  was 
found  to  contain  a  portion  of  adherent  omentum,  together  with  a  very  much  congested 
knuckle  of  small  gut.  The  strangulating  band  was  incised,  the  gut  withdrawn,  and, 
being  in  a  viable  condition,  was  replaced.  The  protruding  portion  of  omentum  was 
liberated,  tied,  and  cut  off.  In  replacing  it,  extensive  adhesions  of  the  stump  to  the 
parietal  peritonaeum  could  be  felt  inside  of  the  abdominal  cavity.  The  sac  was  excised 
and  the  wound  closed  and  dressed  in  the  usual  manner.  May  12th. — Change  of  dressings. 
The  wound  was  found  united,  but  the  general  condition  of  the  patient  had  remained 
the  same  as  before  the  operation.  Gradually  considerable  ascites  developed,  the 
patient  continuing  to  complain  of  much  colicky  pain  ;  the  vomiting  and  lack  of  appetite, 
together  with  rebellious  constipation,  seemed  to  Justify  the  assumption  of  a  general 
morbid  condition  of  the  peritonasum,  namely,  either  tuberculosis  or  a  neoplasm.  May 
2Gth. — The  peritoneal  cavity  was  reopened  at  the  site  of  the  cicatrix  left  by  herniotomy, 
and  extensive  tubercular  degeneration  of  the  entire  peritonaeum,  with  dense  infiltration 
of  the  omentum  and  almost  universal  agglutination  of  the  intestines,  were  found.  The 
parietal  peritonaeum  and  the  gut  were  literally  covered  with  a  mass  of  miliary  white 
nodules.  With  a  view  to  relieving  the  obstruction  caused  by  the  multiple  adherence 
of  the  bowels,  a  protruding  part  of  the  thick  gut  was  attached  to  the  wound  by  a 
number  of  catgut  stitclies,  and  the  external  incision  was  packed  with  iodoformized 
gauze.  May  28th. — The  bowel  was  found  well  united  with  the  parietal  peritonaeum,  and 
an  artificial  anus  was  established  by  incising  the  gut  and  sewing  the  mucous  mem- 
brane to  the  skin.  Sufficient  stools  followed,  but  the  patient  died,  March  31st,  of 
exhaustion. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD. 


119 


The  case  is  interesting  on  account  of  the  coincidence  of  tuberculosis 
of  the  peritonaium  with  strangulation  of  a  femoral  hernia  of  old  standing. 
Of  course,  successful  herniotomy  could  not  avert  impending  death. 

Twent^'-three  (including  those  subjected  to  the  radical  operation)  of  the 
author's  total  of  thirty-one  herniotomized  patients  recovered. 

a.  Herniotomy  for  Strangulation. — If   gentle   and  not  too   prolonged 
efforts  at  reduction,  first  without  then  with  ansesthesia,  do  not  succeed, 
herniotomy  should  be  done  forthwith. 
The  mode  of  procedure  is  as  follows  : 

The  patient's  inguinal  region  is  shaved  and  scrubbed  off 
with  soap  and  hot  water,  and  is  disinfected  with  mercuric 
lotion.  Towels  wrung  out  of  corrosive-sublimate  solution  are 
arranged  about  the  field  of  operation,  and  a  free  incision  is 
made  over  the  hernial  swelling  down  upon  the  sac.  The  in- 
cision should  extend 
well  above  the  ingui- 
nal or  femoral  ring, 
and  should  freely  ex- 
pose the  place  ivhere 
the  hernia  emerges 
from  the  abdominal 
toall.  By  doing  this 
the  surgeon  will  be 
enabled  to  divide  the 
constricting  band  un- 
der the  guidance  of 
the  eye,  and  without 
the  necessity  of  in- 
serting the  probe-pointed  knife  into  the  inguinal  or  femoral  canal,  a  cir- 
cumstance that  may,  even  in  the  hands  of  a  cautious  and  expert  surgeon, 
lead  to  cutting  or  laceration  of  the  intestine,  especially  if  it  be  very  brittle, 
or  necrosed,  or  adherent. 

Case  III. — Philip  Trumann,  aged  two  years  and  three  months,  was  presented  to 
the  author  December  11,  1881,  with  a  soft,  fluctuating,  scrotal  swelling  of  the  left  side, 
which,  however,  could  not  be  by  pressure  reduced  in  size.  Congenital  hydrocele  was 
diagnosticated  nevertheless,  as  the  tumor  showed  transparency.  Puncture  with  a 
hypodermic  needle  brought  out  intestinal  contents.  There  were  no  signs  of  strangula- 
tion, therefore  cold  applications  were  ordered,  and  the  child's  mother  was  told  to  return 
the  next  day.  By  December  12tli  all  symptoms  of  strangulation,  with  rather  high 
fever  and  inflammation  of  the  swelling,  had  developed.  Herniotomy  was  done  at  the 
German  Dispensary.  In  opening  the  sac,  the  gut  was  inadvertently  incised.  It  was 
found  that  local  peritonitis  of  the  sac,  with  extensive  fresh  adhesions,  presumably  due 
to  escape  of  fecal  matter  through  the  puncture-hole,  had  taken  place.  The  gut  was 
detached  everywhere  by  the  finger-tips,  the  parts  were  well  disinfected  by  free  irriga- 
tion with  a  two-per-cent  solution  of  carbolic  acid,  and  the  slit  in  the  intestine  was 
closed  with  a  Lembert  suture  of  catgut.  The  strangulating  band  was  then  cut,  and, 
the  intestine  being  replaced,  the  wound  was  sewed  up,  drained,  and  dressed.     Un- 


FiG.  103. — Patient  ready  for  herniotomy  (or  for  any  other 
operation  about  the  genital  region). 


120  RULES  OF  ASEPTIC  AND    ANTISEPTIC  SURGERY. 


Fig.  lO-i. — llerniotomy.     Cutaneous  incision. 


interrupted    recovery    followed.      Januanj   IS,    188£.— The    patient    was    discharged 
cured. 

The  sac  is  carefully  opened  between  two  forceps,  and,  if  possible,  at  a 
place  where  there  is  no  adhesion  to  the  gut.     After  free  division  between 

two  thumb  -  forceps, 
a  careful  inspection 
of  its  contents,  gut 
or  omentum,  or  both, 
should  be  made.  This 
will  be  very  much 
facilitated  by  taking 
up  the  edges  of  the 
incision  made  into 
the  sac  with  a  num- 
ber of  artery  forceps, 
which  will  serve  as 
handles  to  unfold  it 
to  a  funnel,  which 
can  be  easily  looked 
over.  (Fig.  105.) 
Generally  the  gut  will  appear  deeply  congested,  purplish,  or  brownish 
red.  As  long  as  it  is  turgid,  and  is  seen  to  contract  on  pinching,  it  may 
be  assumed  to  be  viable. 

But  it  still  remains  to  be  ascertained  whether  the  points  of  strangulation 
be  alive  or  not.  To 
do  this  the  strangu- 
lating hand  or  hands 
must  he  first  cut  to  a 
sufficient  extent. 

Attempts  to  with- 
draw the  gut  before 
the  strangulation  is 
completely  removed 
may  lead  to  very  seri- 
ous consequences,  es- 
pecially where  necro- 
sis of  the  strangulated 
portion  of  the  intes- 
tine is  present. 

Case  IV. — J.  Schrank, 
saloon-keeper,  aged  fifty - 
nine.  Left  inguinal  stran- 
gulated hernia  of  five  days'  standing.    Herniotomy,  March  8,  1886,  at  the  German  Hos- 
pital.    The  sac  contained  a  large  mass  of  adhering  omentum,  and  a  knuckle  of  deeply 
congested  small  intestine.     It  was  tliouglit  tliat  the  strangulating  band,  corresponding 
to  the  internal  abdominal  ring,  had  been  sufficiently  incised,  and  a  very  gentle  and 


-Jlcrniotomy.     The  opened  liernial  sue  is  held  ai)art 
for  inspection  by  a  number  of  artery  forceps. 


SPECIAL   APPLICATION  OF  THE  ASEPTIC  METHOD.         121 

unsuccessful  attempt  wjis  made  to  withdraw  the  gut.  The  tip  of  tlie  index  was  rein- 
serted as  a  guide,  and,  the  constriction  being  completely  divided,  the  gut  was  easily 
withdrawn.  At  the  same  moment  a  considerable  quantity  of  fecal  matter  was  seen  to 
escape.  It  was  found  that  necrosis  of  the  neck  of  the  strangulated  knuckle  of  gut  had 
taken  place,  and  that  it  had  been  torn  or  cut  during  the  preceding  efforts  at  liberation. 
The  intestine  was  still  further  extracted,  and  was  attached  to  the  skin  by  a  few  silk 
sutures.  After  careful  disinfection,  the  neck  of  the  sac  was  loosely  packed  with  strips 
ofiodoformized  gauze,  and  the  wound  was  inclosed  in  a  moist  dressing.  The  collapsed 
patient  died  two  hours  after  the  operation. 

In  cases  like  the  preceding  one,  the  classical  practice  of  invaginating  the 
tip  of  the  index  into  the  inguinal  canal  or  femoral  ring,  for  the  purpose 
of  cutting  the  strangulating  band,  is  dangerous,  as  it  may  lead  to  injury  of 
the  brittle  gut. 

The  author  has  found  the  gradual  division  of  all  tissues  from  without 
inward  much  safer,  although  it  must  be  admitted  that  the  division  of  the 
fibrous  tissues  located  above  the  place  of  strangulation  is  extensive,  and  often 
practically  converts  herniotomy  into  laparotomy. 

With  a  few  exceptions,  the  author  has  always  employed  open  division 
of  the  strangulating  bands  of  tissue,  and  never  had  reason  to  regret  it.  In 
some  of  the  complicated  cases  he  was  thereby  enabled  to  at  once  gain  a  very 
clear  insight  into  the  relations  of  the  hernia,  and  in  a  great  measure  the 
ultimate  success  of  the  operation  was  attributed  to  that  advantage. 

Case  V. — Fred.  Bormann,  laborer,  aged  thirty-three,  had  been  treated  at  the  Ger- 
man Hospital  without  success  during  several  days  for  internal  intestinal  obstruction 
marked  by  the  usual  symptoms.  On  closer  inspection,  slight  oedema  of  and  somewhat 
indistinct  resistance  at  the  right  inguinal  region  was  noted.  January  17,  1884-. — An 
incision  was  made  exposing  the  external  inguinal  ring,  which  was  seen  to  be  normal. 
The  incision  was  further  extended,  and,  when  most  of  the  fibrous  layers  surrounding 
the  inguinal  canal  had  been  divided,  a  small  but  well-defined  tumor  could  be  seen  and 
felt  occupying  the  inner  aspect  of  the  abdominal  wall  near  the  internal  orifice  of  the 
inguinal  canal.  The  abdominal  wall  was  completely  divided,  and  then  a  small  hernia, 
located  between  the  parietal  peritonaeum  and  the  abdominal  wall,  was  exposed.  The 
sac  being  incised,  a  knuckle  of  small  gut  was  found  contained  within  it.  The  place  of 
strangulation  was  at  the  neck  of  the  sac.  This  was  completely  slit  open,  the  gut  was 
reduced,  and,  the  neck  of  the  sac  being  closed  by  a  purse-string  ligature,  it  was  cut 
away  entirely.  The  incision  in  the  abdominal  wall  was  closed  by  three  tiers  of  catgut 
sutures.     Primary  union  followed.     February  16th. — Patient  was  discharged  cured. 

Case  VI. — Mr.  M.  S.,  aged  thirty-six.  Left  inguinal  hernia,  that  had  been  repeat- 
edly incarcerated,  but  was  reduced  each  time.  April  8,  1885,  it  came  down  again, 
and,  after  prolonged  and  very  energetic  efforts,  the  physician  in  charge  succeeded  in 
replacing  it,  but  the  symptoms  of  strangulation,  notably  vomiting  and  absence  of  alvine 
evacuations,  persisted.  April  l"2tli. — Herniotomy  at  Mount  Sinai  Hospital.  No  ex- 
ternal tumor  could  be  seen,  but  on  palpation  a  dense  resistant  swelling  could  be  felt 
in  the  inguinal  region  within  the  abdominal  wall.  The  region  of  the  external  abdom- 
inal ring  was  freely  exposed  by  an  ample  incision,  and  the  abdominal  wall  was  divided 
above  Poupart's  ligament.  The  hernia  which  had  been  reduced  in  mass  was  then 
reached,  and  was  pushed  out  through  the  inguinal  canal.  The  remaining  portion  of 
the  intervening  abdominal  wall  was  divided,  together  with  the  place  of  strangulation, 


122  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

and,  the  sac  being  tied  and  cut  away,  the  abdominal  wound  was  closed  with  three 
tiers  of  strong  catgut  sutures.  The  wound  healed  kindly.  May  15th. — Patient  was 
discharged  cured. 

It  may  be  said,  then,  that  open  division  offers  great  advantages,  espe- 
cially with  regard  to  the  avoidance  of  injury  to  necrosed  or  very  brittle  gut, 
and  that  its  only  drawback — tlie  increased  size  of  the  incision — is  vastly 
overbalanced  by  the  security  gained  therefrom.  If  the  gut  be  found  ne- 
crosed, it  can  be  safely  withdrawn  from  the  ample  aperture,  and  establish- 
ment of  an  artificial  anus  can  take  place  after  securely  packing  the  neck  of 
the  protruding  knuckle  of  intestine  with  a  sort  of  embankment  of  iodo- 
formized  gauze.  This  packing  of  gauze  serves  as  a  diaphragm  against  infec- 
tion of  the  peritoneal  cavity. 

Out  of  nineteen  cases  of  herniotomy  done  for  strangulation,  undoubted 
gangrene  of  the  gut  was  joresent  at  the  time  of  operation  in  four.  In 
two  of  these  the  necrosed  part  of  the  gut  was  injured  within  the  inguinal 
canal  by  the  unavoidable  manipulations  in  liberating  the  intestine.  In 
those  cases  where  external  or  open  section  was  used,  the  integrity  of  the 
much-decayed  gut  was  preserved.  In  these  latter  cases  the  gangrene  ex- 
tended to  the  free  part  of  the  gut,  and  was  taken  notice  of  before  dissolving 
the  strangulation.  In  the  former  cases,  however,  in  which  the  gut  was 
inadvertently  injured,  gangrene  was  limited  to  the  exact  locality  of  the  con- 
striction, and  was  diagnosticated  only  after  the  mishap. 

The  practical  lesson  to  be  drawn  from  this  experience  is  that  open  incis- 
ion of  the  inguinal  canal  should  be  done  whenever  very  acute  strangulation 
has  existed  for  more  than  four  or  six  hours. 

All  the  patients  upon  whom  necrosed  gut  was  found  died  either  of  col- 
lapse, shortly  after  the  completion  of  the  ojoeration,  or  of  jjeritonitis  due 
to  infection  extending  from  the  place  of  strangulation. 

On  one  of  them  resection  of  the  necrosed  part  of  the  gut  was  practiced, 
with  subsequent  suture.     The  patient  died  of  peritonitis. 

Case  VII. — Catharine  Ilile,  housewife,  aged  sixty-one,  a  very  fat  woman,  having 
a  large  incarcerated  umdilical  hernia,  was  operated  September  24,  1881,  at  her  rooms 
in  the  presence  of  the  family  attendant.  Dr.  Arcularius.  Open  section  of  constricting 
bands,  circumscribed  necrosis  of  the  neck  of  the  protruding  mass  of  transvez-se  colon. 
Exsection  of  six  inches  of  thick  gut  and  of  a  triangular  piece  of  meso-colon,  and  sub- 
sequent enterorrhaphy  with  fine  catgut ;  closure  of  abdominal  cavity.  Peritonitis 
developed  during  the  following  night,  and,  September  25th,  patient  died  with  enormous 
tympanites. 

Immediate  exsection  of  the  necrosed  gut  has  little  to  commend  it.  The 
dangers  of  infection  of  the  peritonaeum  are  almost  insurmountable,  the  com- 
prehensive preparations  required  for  enterorrhaphy  are  usually  not  made, 
and,  the  work  being  extemporized,  generally  lacks  exactitude.  In  addition 
to  this,  the  general  condition  of  the  patients  is  commonly  so  bad,  that  undue 
prolongation  of  aneesthcsia  itself  would  be  very  dangerous.  Therefore,  in 
these  cases,  the  estnbUslnnent  of  an  artificial  anus  is  the  only  proper  thing 
to  do. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        123 

To  young  physicians  the  decision  of  the  question,  whether  the  gut 
be  alive  or  necrosed,  may  offer  a  good  deal  of  difficulty.  The  responsi- 
bility is  great,  and  uncertainty  about  a  point  of  such  importance  extremely 
perplexing.  Where  necrosis  is  fairly  established,  the  shriveled,  parchment- 
like appearance,  the  yellowish-gray  color,  the  absence  of  reflex  motion  on 
pinching,  and  the  great  fragility  will  at  once  characterize  the  condition. 
But  where  necrosis  is  just  developing — that  is,  where  thrombosis  of  the 
terminal  vessels  with  bloody  infarction  has  gone  so  far  as  to  surely  com- 
promise the  integrity  of  the  gut,  but  the  signs  of  necrosis  are  as  yet  unrec- 
ognizable— decision  may  be  very  difficult  indeed. 

The  causes  producing  intestinal  necrosis  are  not  identical  in  different 
cases.  Local,  well-circumscribed  necrosis,  limited  to  the  extent  of  the 
strangulating  ring,  and  very  often  found  in  femoral  hernia,  is  due  to  local 
anemia  produced  by  the  pressure  of  the  constricting  band« 

In  other  cases  the  local  pressure  exerted  by  the  constricting  band  upon 
the  neck  of  the  hernial  contents  may  be  insufficient  to  destroy  the  vitality 
of  the  intestine  in  actual  contact  with  the  constricting  tissues.  But  press- 
ure that  would  be  hardly  sufficient  to  cut  off  arterial  supply,  will  often  com- 
press to  such  an  extent  the  veins  leading  aivay  from  the  strangulated  gut 
as  to  completely  arrest  circulation.  Venous  engorgement  and  gangrene 
of  the  convex  portion  of  the  intestinal  knuckle  are  then  inevitable. 

The  decision  whether  a  portion  of  intestine,  subjected  to  prolonged  acute 
anaemia  by  local  pressure,  is  viable  or  not,  is  comparatively  easy.  In  many 
of  these  cases,  absent  circulation  is  often  restored  to  the  bloodless  parts  under 
the  eyes  of  the  surgeon.  As  soon  as  the  constriction  is  relieved,  minute  red 
streaks  are  seen  to  sjjring  up  across  the  formerly  pale,  bloodless  area  ;  they 
increase  in  number,  and  finally  the  parts  in  question  assume  a  rosy  hue  and 
a  normal  appearance. 

Sometimes,  however,  recovery  of  circulation  is  tardy.  In  these  cases, 
after  amply  dividing  the  strangulating  band,  a  catgut  thread  should  be 
passed  through  the  mesentery  of  the  questionable  looj)  of  intestine,  which 
then  should  be  temporarily  replaced  in  the  abdominal  cavity.  The  time 
required  for  restoring  the  circulation  of  the  gut  is  usefully  employed  in 
attending  to  such  other  procedures  as  may  be  indicated  under  the  circum- 
stances. Dissection  and  removal  of  adherent  omentum,  or  the  dissection 
of  the  hernial  sac,  will  thus  occupy  some  time,  by  the  end  of  which  the  loop 
of  intestine  can  be  withdrawn  from  the  belly  for  examination.  If  the  con- 
ditions be  found  satisfactory,  the  thread  should  be  removed,  and  the  opera- 
tion finished  in  the  usual  way. 

Case  VIII. — Theresa  Wagenglast,  cigarmaker,  aged  thirty -nine,  contracted,  April 
11,  1887,  strangulation  of  a  femoral  hernia  of  old  standing,  situated  on  the  left 
side.  April  15th. — Admitted  to  German  Hospital  with  incessant  vomiting,  induced 
mainly  by  the  administration  of  calomel.  Immediate  herniotomy.  A  considerable 
portion  of  adherent  omentum  presented,  and  was  tied  oft"  in  several  portions  and 
removed.  After  tins  a  very  small  knuckle  of  gut  became  visible,  which  showed  an 
ansemic  area  corresponding  to  the  locality  of  constriction.     Eecovery  being  tardy,  a 


1-24:  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

tliread  of  catgut  was  passed  thi'ough  the  mesentery,  and  the  knuckle  was  replaced  in 
the  abdomen  through  the  well-divided  femoral  ring.  In  the  mean  time  the  sac  was 
excised.  After  the  completion  of  this  step,  requiring  about  fifteen  minutes,  the  gut 
was  re-extracted  for  examination,  and  circulation  was  found  fully  re-established.  The 
gut  being  replaced,  the  neck  of  the  sac  was  closed  with  a  purse-string  suture,  and  was 
pushed  well  up  in  the  femoral  ring.  Drainage  and  suture  of  the  external  wound. 
April  loth. — The  drainage-tube  was  removed.  April  29th. — Patient  was  discharged 
cured. 

Where  impending  gangrene  from  venous  engorgement  is  to  be  feared, 
the  decision  is  generally  more  difficult  than  in  the  preceding  class  of  cases. 
Where  immediate  solving  of  the  momentous  question  is  impossible,  the 
benefit  of  the  doubt  should  always  belong  to  the  assumption  that  necrosis 
is  to  be  expected.  In  these  cases  the  neck  of  the  hernial  sac  should  be  well 
divided  to  secure  the  best  circulation  possible,  and  the  loop  of  gut  should 
be  so  attached  to  the  skin  by  a  couple  of  sutures  passed  through  the  mesen- 
tery as  to  leave  the  questionable  spots  exposed  to  view.  Thorough  disin- 
fection by  wijiing  with  sponges  wrung  out  of  Thiersch's  solution,  a  light 
packing  of  iodoformized  gauze  around  the  neck  of  the  knuckle,  and  a  mnist 
aseftic  dressing  (the  gut  being  covered  by  a  protective  strip  of  rubber  tissue) 
should  be  applied.  If  the  gut  decay,  this  will  take  place  outside  of  the 
peritoneal  cavity.  Should  it  recover,  the  fact  will  be  manifest  within  one 
or  two  hours  after  the  operation.  The  gut  should  be  then  well  disinfected, 
liberated  by  gentle  manipulation  from  its  newly-assumed  position,  and 
replaced  in  the  abdominal  cavity. 

Case  IX  illustrates  the  consequences  of  the  replacement  of  the  gut  of 
doubtful  vitality.     It  was  the  author's  first  herniotomy. 

Case  IX. — John  Philip  lores,  waiter,  aged  fifty-three.  Very  acute  strangulation 
of  twelve  hours'  standing  of  an  old,  right  inguinal  hernia.  October  ^7,  1878. — Herni- 
otomy in  presence  of  Dr.  L.  Bopp,  the  family  physician.  Two  knuckles  of  deeply- 
injected  small  intestine,  aggregating  to  the  length  of  ten  inches,  and  a  mass  of  dark- 
blue  omentum  were  found  in  the  sac.  But,  as  the  gut  seemed  to  be  turgid  and  viable, 
it  was  replaced.  The  omentum  was  pulled  out,  tied  and  cut  off,  and  the  stump  was 
replaced.  Septic  symptoms  set  in  immediately  after  the  operation,  with  high  fever 
and  very  great  debility.  October  29th. — Unmistakable  signs  of  peritonitis,  notably 
enormous  meteorism,  appeared.  The  restless  patient  disarranged  the  dressings  during 
his  tossing  in  bed,  and,  while  vomiting,  the  adhesions  of  the  wound  gave  way,  and 
a  large  loop  of  intestine  prolapsed.  Necrosis  of  a  portion  of  the  prolapsed  gut  was 
evident.  As  much  of  it  as  was  normal  was  replaced,  the  decayed  part  of  the 
gut  was  incised,  and  fixed  near  the  external  wound.  The  patient  died  shortly 
afterward. 

It  must  be  added  that,  according  to  then  prevailing  notions  (1878),  the 
sac  and  its  contents  were  washed  with  a  strong  solution  of  carbolic  acid 
(5  :  100)  before  the  gut  was  replaced.  Superficial  ei'osion  of  the  intestinal 
peritonaeum  may  have  had  its  share  in  precipitating  both  gangrene  and  peri- 
tonitis. 

Necrosis  of  the  vermiform  appendix  was  observed  by  the  author  once 
with  fatal  termination. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.         125 

Case  X. — Henrietta  Baulnnd,  aged  forty-seven.  Right  femoral  hernia  of  forty- 
eight  hours'  standing.  April  18,  188 Jf. — Herniotomy  at  the  German  Hospital.  Vermi- 
form appendix  was  found  attached  by  its  apex  to  the  side  of  the  sac ;  a  knuckle  of 
small  intestine  was  embraced  in  the  loop  formed  by  the  vermiform  appendix,  and  then 
doubly  incarcerated.  Manipulation  was  very  difficult,  on  account  of  the  narrow  space 
and  tlie  complicated  state  of  things.  The  gut  was  slightly  torn,  but  no  intestinal  con- 
tents escaped.  Two  Lembert's  sutures  being  applied,  the  strangulation  at  the  neck  of 
the  sac  was  relieved  and  the  gut  was  liberated.  The  middle  part  of  the  vermiform 
appendix  was  found  necrosed,  and,  a  ligature  being  applied  above  this  part,  the  appen- 
dix was  cut  away.  The  gut  was  returned.  The  patient  got  on  very  well  until  April 
25th,  when  perforative  peritonitis  developed.  April  27th. — Patient  died.  No  autopsy 
could  be  secured. 

However  desirable  thoroughness  and  deliberation  may  be  in  herniotomy, 
undue  prolongation  of  anaesthesia  is  an  evil  fraught  with  especial  danger  in 
cases  of  long-contintied  strangulation,  on  account  of  the  cardiac  debility 
present.  When  the  patient's  vitality  has  been  much  lowered  by  continuous 
vomiting,  loss  of  sleep,  and  septic  fever,  even  a  brief  anaesthesia  may  be 
sufficient  to  precipitate  fatal  collapse.  Habitual  users  of  alcohol  and  obese 
individuals  are  very  poor  subjects  to  endure  anaesthesia  in  the  presence  of 
necrosis  of  the  gut. 

Case  XI. — Albert  P.,  drayman,  aged  thirty-five,  moderate  but  steady  consumer  of 
beer  and  whisky.  Incarcerated  right  inguinal  hernia  of  seventy-five  hours'  duration. 
The  swelling  was  mistaken  for  acute  orchitis,  hernia  being  thought  of  by  the  family 
attendant  only  after  fecal  vomiting  had  set  in.  March  19,  1887. — Herniotomy  at  the 
German  Hospital.  Extensive  gangrene  of  the  small  gut  was  found.  Ether  anaesthesia 
was  very  bad,  the  patient  struggling  all  the  while  during  the  operation.  If  ether  was 
crowded,  respiration  became  irregular,  the  face  pallid,  and  syncope  threatening.  Arti- 
ficial anus  was  established,  and  the  case  was  finished  with  all  possible  expedition, 
anaesthesia  lasting  altogether  for  thirty  minutes.  Deep  collapse  following,  the  patient 
did  not  rally  in  spite  of  copious  hypodermic  stimulation,  and  he  died  two  hours  after 
the  completion  of  herniotomy. 

It  is  plausible  to  assume  that  in  similar  cases  herniotomy  performed 
with  the  aid  of  local  anaesthesia  would  offer  better  chances  of  success  than 
if  it  be  done  in  general  ether  or  chloroform  narcosis. 

The  last  one  of  the  eight  fatal  cases  died  of  acute  septicsemia  induced  by 
diphtheritic  enteritis  of  the  strangulated  knuckle  of  gut. 

Case  XII. — Charles  Etzler,  baker,  aged  thii-ty-five.  Very  acute  strangulation,  of 
fifty  hours'  standing,  of  an  old  right  inguinal  hernia.  The  patient  had  had  no  medical 
care  until  a  few  hours  before  his  admission  to  the  German  Hospital,  when  Dr.  H.  Kudlich 
was  called  in.  He  was  requested  to  stop  the  violent  fecal  vomiting  caused  by  a  very 
large  dose  of  Eochelle  salts  taken  in  the  morning  of  January  31,  1884.  Herniotomy  on 
the  evening  of  the  same  day.  The  large  scrotal  hernia  contained  a  good-sized  portion 
of  adherent  omentum  and  a  massive  conglomerate  of  several  knuckles  of  small  gut, 
bound  together  by  firm  cicatricial  adhesions  of  old  date.  Free  external  Incision  of  the 
abdominal  wall  until  the  neck  of  the  hernial  sac  was  completely  divided.  The  gut 
looked  tolerably  well  preserved  and  was  replaced ;  the  omentum  was  freed  by  dissec- 
tion, and,  being  tied  off  in  several  portions,  was  cut  oflf.  The  stump  being  replaced,  the 
sac  was  tied  and  cut  off;  then  the  abdominal  wall  was  sutured  by  several  tiers  of 
18 


126  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

strong  catgut  in  physiological  order.  The  outer  wound  was  drained,  sewed,  and 
dressed  as  usual.  February  1st  passed  off  without  any  outward  symptom,  the  vom- 
iting having  ceased  immediately  after  the  operation.  February  2d. — A  severe  chill 
with  much  belly-aclje  set  in,  but  no  raeteorism  appeared  until  February  4th,  the 
thermometer  indicating  all  the  while  105°  F.  The  patient's  condition  grew  steadily 
worse,  with  deep  coma,  jaundice,  and  petechial  patches  on  the  legs.  February  5th. — 
The  sutures  gave  way  during  a  vomiting  spell,  and  a  loop  of  healthy-looking  gut  pro- 
lapsed. It  was  not  replaced.  Shortly  after  the  patient  died.  Post-mortem  examina- 
tion revealed  a  slaty  discoloration  of  the  mentioned  bunch  of  coherent  gut,  which, 
being  incised,  appeared  to  be  covered  on  its  mucous  side  with  a  large  number  of  round 
and  contluent  whitish-gray  adherent  patches  of  membrane,  which  involved  the  intes- 
tinal wall  to  varying  depths,  some  of  them  being  visible  through  the  peritoneal 
covering.     No  peritonitis. 

The  author  is  at  a  loss  for  an  explanation  of  this  rare  form  of  di23h- 
theritic  affection  of  the  bowel. 

Seven  of  the  successful  operations  for  strangulation  w^ere  done  on  in- 
guinal (one  preperitoneal,  Case  V),  four  on  femoral,  hernise. 

Cured 11  patients 

Died 8        " 

Total 19 

In  dividing  the  strangulating  band  in  femoral  hernia,  the  incision  should 
be  directed  inward  toward  Gimbernat's  ligament.  But,  where  the  space  is 
very  narrow  or  the  condition  of  the  gut  doubtful,  free  incision  of  the 
fascia  lata  parallel  to  the  large  vessels,  and  preparatory  exposure  of  the 
femoral  canal,  would  be  more  proper. 

To  incise  the  strangulating  bands  sufficiently  to  enable  the  surgeon  to 
withdraw  additional  portions  of  gut  for  examination  does  not  insure  facile 
reposition  by  any  means  ;  and  forcible  crowding  back  of  the  congested  and 
vulnerable  intestine  through  an  insufficiently  wide  orifice  may  lead  to  its 
rupture.  Therefore,  the  dilatation  must  be  very  ample  to  permit  easy  reposi- 
tion without  the  use  of  undue  force. 

As  long  as  the  sac  is  not  closed,  and  communication  is  open  with  the 
peritoneal  cavity,  irrigation  of  the  wound  must  stop,  otherwise  large  jior- 
tions  of  the  lotion  may  find  their  way  into  the  abdomen.  The  use  of  strong- 
solutions  of  carbolic  acid  or  mercuric  bichloride  on  the  prolapsed  gut  is 
not  advisable  and  is  unnecessary.     As  soon  as  the  gut  is  replaced,  the  sac 

should  be  wiped  clean  with  a  disinfected  sponge, 
and  another  small  sponge,  fastened  to  a  thread  of 
catgut,  should  be  pushed  into  the  inguinal  canal 
to  serve  as  a  barrier  to  the  influx  of  blood  into 
the  peritoneal  cavity.  If  the  patient  is  seen  to 
bear  anaesthesia  well,  inguinal  herniotomy  can  be 
supiDlemented  by  the  addition  of  Czerny's  suture 
of  the  inguinal  ring,  as  described  under  the  head- 

Fio.   106.— Purse-strinir  siit-     ing  of  "  Radical  Operation  of  Hernia." 

lire,  employed  for  occliKlinjr  ,,,        it,  n  i  .  •  • 

the  neck  of  the  hernial  sito.  ^^houJd,  howcvcr,  coiiapsc  DC  present  or  immi- 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        127 


uent,  and  prolongation  of  ana?s- 
thesia  inadvisable,  a  thread  of 
strong  catgut  is  passed  through 
the  neck  of  the  sac  (see  cut)  as 
high  up  as  possible,  assistants 
holding  well  apart  the  arter}'  for- 
ceps by  which  the  edges  of  the 
cut  through  the  sac  are  secured. 
This  suture  resembles  a  purse- 
string  in  its  working  (Fig.  106). 
It  is  tightened  and  knotted,  and 
will  securely  occlude  the  perito- 
neal caYity.  Then  the  external 
wound  is  well  irrigated  with  cor- 
rosive-sublimate lotion,  a  drain- 
age-tube is  placed  well  up  to  the 
purse-string  suture,  and  the  edge: 
gut  stitches 


107. 


Suture  of  external  wound. 


of  the  skin  are  brought  together  with  cat- 
The  dry  dressings  are  applied  so  as  to  cover  up  the  scrotum 

and  both  inguinal  regions,  a  slit 
being  left  in  the  middle  for  the 
jDenis,  which  should  protrude  from 
the  bandages.  The  use  of  a  "  hip- 
rest  "  Avill  facilitate  the  application 
of  the  otherwise  difficult  dressing. 
In  ptrivate  practice,  a  common 
hassock  or  footstool,  wrapped  in 
a  clean  towel  or  slijjped  into  a 
clean  pillow-case,  will  make  a  caj)- 
ital  hip-rest. 

In  female   patients  the   com- 
The  dressings  should  fit  snugly, 


Fig.  108. — Volkmann's  "  hip-rest.' 


presses  are  held  down  by  a  spica  bandage 

especially  about  the  edges,  and  should  not  be  too  scanty. 

Six  or  seven  days  after  the  op- 
eration the  dressings  should  be 
changed,  to  permit  withdrawal  of 
the  drainage-tube.  Five  or  six 
days  more  will  complete  the  es- 
sential part  of  the  cure. 

The  patient's  bowels  should 
be  moved  forty-eight  hours  after 
the  operation  by  a  large  enema 
of  soap-water.  Should  fever  set 
in  from  peritoneal  irritation,  a 
saline  purge  may  be  administered 
with  good  effect. 

As  long  as  the  patient  is  in 


Fig.  109. 


-Manner  of  applying  dressing  for  wounds 
of  scroto-ino-uinal  region. 


128 


EULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


bed,  initrition  should  be  simple  aud  moderate.     No  patient  should  be  per- 
mitted to  go  about  his  business  before  a  truss  can  be 
worn  with  comfort.     But  there  is  no  objection  to  his 
being  up  and  about  the  room  with 
a  well-fitting  pad  and  spica. 


Fig.  110.— Herniotomy.     I'atient  on  "  hip-rest,"  with  completed  dressing.     Lateral  view. 


Synopsis  of  successful  cases  hither 

Case  XIII.— Mrs.  C.  Reinhardt, 
of  three  days'  duration.     Operation, 


Fig.  111. — Completed  dressing  of  scroto-ignuinal  region 
Anterior  view. 


to  not  accounted  for  : 

aged  fifty-four,  left  inguinal  incarcerated  hernia 
November  15,  1882.     Cured,  December  11th. 

Case  XIV. — Chas.  Roensch, 
four  months  old,  congenital  in- 
carcerated hernia.  Operation 
in  German  Dispensary,  Janu- 
ary 26,  1883.  Cured,  Febru- 
ary 22d. 

Case  XV.— G.  John.  See 
history,  page  24. 

Case  XVI. — Fred.  Hipp,  me- 
chanic, aged  sixty,  right  exter- 
nal inguinal  hernia.  Operation 
at  German  Hospital,  April  6, 
1884.     Cured,  May  1st. 

Case  XVII.— Mrs.  Emma  T., 
aged  forty-seven,  left  femoral 
hernia.  Operation,  March  25, 
1887.     Cured,  April  10th. 

Case  XVIII. — Anna  Brown, 
aged  fifty,  left  femoral  hernia. 
Operation  at  Mount  Sinai  Hos- 
pital in  September,  1880.  Dis- 
charged cured,  end  of  October. 

Case  XIX.— Martin  Thor- 
Operation,    February   12,    1880. 


warth,   cooper,   aged  sixty,   right  inguinal  hernia. 
Cured,  Marcii  5th. 

b.  Radical  Operation  for  Hernia. — In  performing  herniotomy  for  stran- 
gulation on  a  patient  whose  general  condition  is  good,  the  additional  steps 
for  radical  cure  may  be  at  once  carried  out  to  great  advantage. 

In  other  cases  of  non-strangulated  hernia,  where  retention  by  truss  of  a 
very  large  scrotal  hernia  is  impracticable  on  account  of  wide  distention  of 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        129 

the  inguinal  eantil,  or  where  adhesions  of  the  })ro]apsed  gut  or  omentum  to 
the  sac  render  reduction  impossible  and  make  attempts  at  wearing  a  truss  a 
torture  to  the  patient,  radical  operation  is  proper  and  justified.  Due  ob- 
servance of  the  rules  of  asepsis  makes  this  operation  very  safe  as  far  as  the 
production  of  purulent  peritonitis  is  concerned.  Still,  some  danger  of 
septic  infection  can  never  be  excluded  with  positive  certainty.  Therefore, 
bloody  radical  operation  should  be  discouraged  for  a  hernia  that  can  be 
retained  by  a  properly  constructed  truss. 

The  author  has,  in  the  main,  followed  Czerny's  directions  in  performing 
radical  operation  of  hernia,  the  several  steps  of  which  are  as  follows  : 

After  due  preparation  by  a  laxative,  preferably  castor-oil,  the  patient's 
pubic  region  and  scrotum,  especially  on  the  side  of  the  rupture,  are  shaved 
and  cleansed  the  day  before  the  operation,  with  brush,  soap,  and  hot  water, 
and  are  wrapped  up  in  a  clean  towel  dipped  in  a  three-per-cent  solution  of 
carbolic  acid.  This  wet  compress  is  again  covered  with  a  suitable  piece  of 
oiled  silk  or  rubber  tissue,  and  fastened  on  with  a  T-bandage. 

On  the  day  of  the  operation  the  patient  is  placed  on  the  table  and  anaes- 
thetized, a  full  and  good  anaesthesia  being  especially  desirable.  After  re- 
peated disinfection,  the  hernial  sac  is  exposed  by  a  sufficiently  long  incision, 
in  which  all  bleeding  vessels  are  to  be  secured  by  ligature.  The  upper 
angle  of  the  wound  should  be  located  well  above  the  upj)er  margin  of  the 
inguinal  ring  so  as  to  permit  easy  manipulation. 

The  sac  is  incised,  and  its  edges  are  taken  up  by  a  number  of  artery 
forceps,  which  being  held  apart,  an  excellent  view  of  the  contents  of  the 
hernia  can  be  had.  Adhesions  of  the  omentum  to  the  sac  will  be  found  the 
most  common  cause  of  the  irreducibility,  the  gut  being  rarely  adherent. 
The  author  has  observed  only  one  case  of  old  hernia  in  which  adhesions  of 
the  gut  were  present  (case  Mau).  The  favorite  place  of  omental  adhesions 
is  the  anterior  portion  of  the  neck  of  the  sac. 

As  soon  as  the  sac  is  open,  the  use  of  the  irrigator  has  to  be  discon- 
tinued, to  prevent  entrance  of  large  quantities  of  irrigating  fluid  into  the 
peritoneal  cavity.  The  lotions  used  for  rinsing  hands,  sponges,  and  instru- 
ments ought  to  be  very  mild  to  prevent  even  superficial  corrosion  of  the 
peritonaeum.  The  author  has  generally  used  Thiersch's  boro-salicylic 
solution. 

A  suitable  sponge,  fastened  to  a  stout  piece  of  silk  or  catgut,  is  pushed 
well  up  into  the  inguinal  canal  to  prevent  the  entrance  of  blood  into  the 
abdomen.  Care  must  be  taken  not  to  select  a  too  brittle  sponge,  as  it  may 
happen  that,  on  removing  it,  some  portion  of  it  may  become  detached  and 
remain  in  the  belly. 

The  sac  must  be  split  open  to  within  a  quarter  of  an  inch  of  the  external 
inguinal  ring,  and  the  adherent  omentum  must  be  detached  from  the  sac 
by  preparation.  As  soon  as  the  distal  attachments  of  the  omentum  are 
severed,  it  is  withdrawn  a  little  farther  from  the  inguinal  canal,  and,  being 
deligated  in  small  portions  with  reliable  catgut,  it  is  cut  away  by  the  knife, 
or,  preferably,  the  thermo-cautery.     After  this  the  sac  is  wiped  out  cleaUj, 


130  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

and,  the  sponge  being  withdrawn  from  the  inguinal  canal,  the  stump  of  the 
omentum  is  rej)laced  in  tlie  abdominal  cavity. 

In  dissecting  up  adherent  gut,  great  caution  must  be  observed  not  to  in- 
jure it.  Where  the  adhesions  are  very  close  and  extensive,  it  would  be 
better  to  excise  the  attached  portion  of  the  sac  with  the  gut,  and  replace 
them  together  in  the  peritongeum. 

Case  I. — Henry  Mau,  slioeinaker,  aged  sixty-two.  Very  large  scrotal  hernia,  con- 
taining adherent  gut.  The  inguinal  ring  was  so  dilated  that  the  tips  of  three  fingers 
could  easily  be  slipped  within  the  abdominal  cavity.  February  23,  1886. — Radical  op- 
eration at  tlie  German  Hospital.  Ether  antesthesia  produced  violent  retching  and 
coughing,  so  that  the  irresistible  escape  of  gut  from  the  wound  rendered  operation 
impossible.  Chloroform  being  administered,  quiet  anesthesia  was  achieved.  The  ad- 
herent thick  gut  was  dissected  away,  together  with  the  adhering  portions  of  the  sac, 
and  was  returned  to  the  abdominal  cavity.  The  remnant  of  the  sac  was  separated, 
closed  at  its  neck  with  a  purse-string  suture,  and  was  cut  away.  The  wide  gap  of  the 
inguinal  ring  was  closed  with  eight  sutures  of  stout  catgut,  and  the  external  wound 
was  drained  and  sewed  up.  Uninterrupted  recovery.  March  25th. — The  patient  was 
discharged  cured  with  instructions  to  wear  a  light  truss.  In  November,  1886,  he  pre- 
sented himself  with  a  relapse.  His  truss  had  been  broken,  and  he  neglected  to  have  it 
repaired.     In  a  fit  of  violent  coughing  the  rupture  reappeared. 

The  contents  of  the  sac  being  disposed  of,  excision  of  the  sac  is  the  next 
thing  to  be  done. 

In  most  cases  this  can  be  readily  accomplished  by  stripping  up  the  sac 
from  the  surrounding  tissues  with  the  fingers,  the  scissors  being  only  occa- 
sionally needed  to  sever  resisting  bands,  which  generally  contain  vessels 
requiring  ligature.  In  some  instances,  however,  especially  in  cases  of  con- 
genital hernia,  the  separation  of  the  sac  is  not  easy.  The  sac  proper  is  not 
well  defined,  and  in  some  localities  consists  of  nothing  but  the  bare  peri- 
tonaeum. Hence  it  is  difficult  to  get  it  out  uninjured  and  in  one  piece. 
Another  difficulty  is  jDresented  by  the  close  relations  of  the  cord  and  its 
vessels  to  the  sac.  The  greatest  care  must  be  taken  to  properly  recognize 
them,  as  otherwise  they  may  be  accidentally  damaged. 

Case  II. — William  Litzebauer,  baker,  aged  twenty-seven.  Left  inguinal  irreducible 
hernia.  February  5,  1886. — Radical  operation  at  the  German  Hospital.  Liberation 
of  adherent  omentum,  which  was  deligated  and  cut  away.  In  dissecting  up  the  sac, 
the  vas  deferens  was  cut  across.  A  short  piece  of  stout  catgut  was  introduced  into  the 
patent  ends  of  its  lumen,  and  the  duct  was  united  by  four  fine  catgut  sutures  passed 
through  its  involucrum.  The  sac  being  removed,  the  external  ring  was  closed  by  six 
stout  catgut  sutures.  The  external  wound  was  drained  and  sewed,  February 
7th. — Purulent  urethral  discharge  was  noted;  no  fever.  February  i5i/i.— Change 
of  dressings.  Wound  healed  by  adhesion,  left  testicle  somewhat  swollen  and  pahi- 
ful.  Tube  was  removed.  February  27th. — Urethral  discharge  disappeared,  testicle 
notably  decreased  in  size.  March  10th. — Discharged  cured,  with  slightly  enlarged 
testis. 

Congenital  irreducible  liernia  is  comparatively  frequent.  Four  of  the 
twelve  cases  operated  on  by  the  author  belonged  to  this  class.  One  was  com- 
plicated with  undescended  testicle. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         131 

In  two  of  these  cases  castration  had  to  be  performed  along  with  tlie  radi- 
cal operation. 

Case  III. — August  B.,  painter,  aged  twenty-fDur.  August  23,  1883. — Radical 
ooeratlon  at  the  German  Hospital.  The  omentum  was  found  adherent  to  the  left  testi- 
cle, and  contained  near  its  adhesion  to  this  organ  a  hard,  pigmented  tumor  of  the  size 
of  a  walnut.  The  sac  and  the  tunica  propria  of  the  testis  were  dotted  with  a  large 
number  of  pigmented  spots.  Tlierefore  the  omentum,  sac,  and  testicle  were  all  re- 
moved. Closure  of  inguinal  ring  by  catgut  sutures.  Treatment  of  external  wound 
as  usual.     Septeniber  20th. — Discharged  cured. 

Case  IV. — George  AV.,  cattle-raiser,  aged  thirty-six.  Direct  inguinal  hernia  of 
left  side,  containing  the  undescended  testicle.  August  24,  1885. — Radical  operation  at 
Mount  Sinai  Hospital.  The  attached  omentum  was  freed  and  removed.  The  atrophic 
testicle  was  also  taken  away.  Suture  as  usual.  SejAemher  Jftli. — Patient  strained  at 
stool,  whereupon  the  external  wound  reopened,  but  subsequently  healed  by  granu- 
lation.    October  2d. — Patient  was  discharged  cured. 

In  a  third  case  of  congenital  hernia,  in  an  infant,  eclamptic  attacks 
caused  repeated  protrusion  of  the  intestine,  that  could  not  be  reduced  with- 
out the  employment  of  anaesthetics. 

Case  Y. — Carl  Schlichter,  eight  months  old.  April  18,  1886. — Prolapse  of  the 
gut  during  a  convulsive  seizure.  Dr.  Meltzer,  tiie  family  attendant,  administered  chloro- 
form, whereupon  the  author  reduced  the  gut  with  some  difficulty.  The  accident  had 
occurred  the  fourth  time  in  spite  of  a  truss.  Radical  operation  was  at  once  performed. 
May  5th. — Patient  discharged  cured. 

Case  VI. — Franz  Faulhaber,  laborer,  aged  twenty-two.  Left  congenital  omental 
hernia.  July  28,  1885. — Radical  operation  at  the  German  Hospital.  Omentum  adher- 
ing to  sac  treated  as  usual.  Sac  was  cut  away  below  from  its  reflexion  upon  the  testi- 
cle, and  above  close  beneath  the  purse-string  suture.  Treatment  of  inguinal  ring  and 
external  wound  as  usual.  Uninterrupted  cure.  September  1st. — Patient  was  discharged 
cured. 

The  closure  of  the  sac  is  to  be  done  by  the  purse-string  suture,  depicted 
by  Fig.  106.  Rather  stout  catgut  must  be  used  for  this,  to  withstand  the 
powerful  tension  required  for  closing  the  circular  suture.  The  sac  is  cut 
away  below  the  knot,  and  any  bleeding  vessels  must  be  separately  de- 
ligated.  The  stump  is  pushed  well  up  within  the  internal  abdominal 
ring. 

In  applying  Czerny^s  sutiire  of  the  inguinal  ring,  the  left  index-finger 
is  intruded  as  far  as  possible,  its  volar  aspect  being  directed  downward  and 
inward  to  protect  the  cord,  which  should  be  kept  near  the  inferior  and  inner 
angle  of  the  slit  of  the  inguinal  aperture.  A  strongly  curved  needle,  armed 
with  stout  catgut,  is  passed  first  through  one,  then  through  the  other  pillar 
of  the  ring,  and  the  ends  of  the  thread  are  secured  in  a  pair  of  artery  for- 
ceps, and  reflected  upon  the  abdomen,  where  they  are  received  by  an  assist- 
ant. This  first  suture  should  be  placed  as  high  wp  the  inguinal  ring  as 
possible.  In  intervals  of  a  third  of  an  inch  from  four  to  seven  stitches  are 
applied  in  the  manner  indicated  ;  then  they  are  tied  firmly  by  surgeons' 
knots  in  the  reverse  order.  A  small -sized  drainage-tube  is  placed  in  the 
wound,  and  the  integument  is  united  by  finer  catgut  sutures,  the  tube  being 


132  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

brought  out  through  the  lower  angle  of  the  incision.  An  antiseptic 
dressing  is  next  applied  in  the  manner  shown  by  Figs.  108,  109,  110, 
and  111. 

The  first  change  of  dressings  should  be  made  on  the  tenth  day,  when 
the  tube  is  also  removed.  As  soon  as  the  wound  is  completely  closed,  the 
patient  is  permitted  to  get  up  with  a  spica  bandage  or  truss. 

The  patients  should  be  directed  to  continue  the  use  of  a  light  truss,  as 
this  is  the  only  reliable  security  against  recurrence. 

In  one  case  a  fibromatous  node  in  the  adherent  omentum  was  the  chief 
source  of  pain  complained  of  by  the  patient. 

Case  VII. — Jacob  ChristmanD,  laborer,  aged  thirty-nine.  August  15,  1885. — Eadi- 
cal  operation  at  the  German  Hospital.  A  hard,  irregular  node  was  occupying  the  mid- 
dle of  the  prolapsed  and  adherent  omentum.  It  was  removed  with  the  same.  Dis- 
charged cured,  September  19th.     The  node  was  tibromatous  in  character. 

In  another  case  a  subserous  fibro-lipoma  was  located  outside  of,  and  was 
closely  connected  with,  the  neck  of  the  sac. 

Case  VIII. — Carl  Dille,  laborer,  aged  thirty.  Subserous  fibro-lipoma  and  left 
adherent  omental  hernia.  March  if,  1887. — Eadical  operation  at  the  German  Hos- 
pital. Removal  of  omentum  and  sac,  together  with  neoplasm.  Sutures  as  usual.  April 
9th. — Discharged  cured. 

The  remaining  four  cases  presented  nothing  unusual,  and  all  recoyered 
without  mishap  : 

Case  IX. — Charles  Niemann,  locksmith,  aged  tliirty.  Adherent  left  omental  hernia. 
February  19,  1887. — Radical  operation  at  the  German  Hospital.  March  12th. — Dis- 
cliarged  cured. 

Case  X. — Martin  Hussmann,  baker,  aged  twenty-five.  Adherent  right  omental 
hernia.  March  3,  1887. — Eadical  operation  at  the  German  Hospital.  April  7th. — 
Discharged  cured. 

Case  XI. — Henry  Mehle,  barber,  aged  twenty-five.  Adherent  right  omental  hernia. 
January  8,  1886. — Eadical  operation  at  the  German  Hospital.  February  12th. — Dis- 
charged cured. 

Case  XII. — Mr.  M.  D.,  merchant,  aged  thirty-nine.  Very  massive,  growing,  adher- 
ent omental  hernia  of  the  right  side.  May  26,  1887. — Eadical  operation  at  Mount  Sinai 
Hospital.     June  16th. — Patient  discharged  cured. 

It  has  been  urged,  notably  by  Weir  and  Abbe,  of  New  York,  that,  after 
radical  operation,  healing  of  the  external  wound  by  granulation  is  preferable 
to  primary  union,  on  account  of  the  larger  mass  of  cicatricial  matter  result- 
ing from  the  granulating  process.  To  the  author  this  advantage  seems  of 
doubtful,  certainly  of  only  passing,  value,  as  the  massive  cicatrix,  first  hard 
and  resisting,  must  in  the  course  of  time  become  atrophied,  soft,  and  yield- 
ing, and  will  7iot  be  able  to  withstand  for  a  long  time  the  constant  impact 
of  the  intra-abdominal  pressure.  The  analogy  of  this  fact  with  the  experi- 
ences gathered  about  the  wounds  resulting  from  laparotomy  can  not  be  gain- 
saifl.  These  regularly  terminate  in  ventral  hernia  when  the  healing  of  the 
abdominal  incision  was  not  by  primary  union,  and  tlie  cicatrix  produced  by 
a  long  process  of  granulation  is  very  wide  and  massive. 


SPECIAL   APPLICATION   OF  THE  ASEPTIC   METHOD.         133 

3.  Laparotomy. 

a.  Exploratory  Incision. — Although  the  aseptic  method  has  very  mate- 
rially reduced  the  dangers  of  exploratory  laparotomy,  its  wanton  and  un- 
necessary practice  must  be  deprecated  on  several  grounds.  Firnt  of  all, 
no  surgeon  is  absolutely  secure  in  his  practice  against  accidental  and  un- 
expected, often  unexplained,  wound  infection.  Secondly,  the  dangers  of 
anaesthesia,  and  of  conditions  indirectly  caused  by  it,  as  nephritis,  pneu- 
monia, thrombosis,  and  embolism,  are  ever  present,  and  usually  surprise 
the  surgeon  when  least  expected. 

Exploratory  incision  is  only  justified  where,  in  the  presence  of  a  disorder 
threatening  life,  all  known  means  for  establishing  a  diagnosis  have  been 
exhausted  without  positive  result,  or  where  the  extent  and  exact  relations 
of  a  mechanical  disturbance  can  not  be  estimated  without  ocular  inspection 
and  digital  examination. 

Due  observance  of  the  rules  against  infection  will  exclude  suppurative 
peritonitis  with  great  certainty.  The  detail  of  the  procedure  is  treated  in 
the  chapter  on  abdominal  tumors. 

Case  T.— Fred.  Kahn,  aged  eleven.  Intestinal  obstruction  of  seven  days'  duration. 
Fecal  vomiting,  very  great  tympanites,  and  threatening  exhaustion.  No  fever.  June 
27,  1882. — Lapal-otomy  under  ether.  In  the  right  iliac  fossa  an  immovable  convolu- 
tion of  small  gut  could  be  felt.  The  incision  was  sufficiently  extended  to  enable  the 
author  to  inspect  the  locality.  It  was  found  that  the  tip  of  the  vermiform  appendix 
was  attached  to  the  parietal  peritonaeum.  A  large  loop  of  the  ileum  had  slipped  through 
tlie  hiatus  thus  formed,  and  was  there  incarcerated.  The  vermiform  appendix  was  cut 
between  tw^o  ligatures,  and  the  loop  of  intestine  became  free.  Reduction  of  the  enor- 
mously distended  intestines  was  impossible.  At  the  suggestion  of  Dr.  A.  Seibert,  an 
enema  was  administered,  and  it  brought  away  a  large  quantity  of  gas,  whereupon  the 
somewhat  collapsed  gut  could  be  replaced,  and  the  abdominal  incision  closed.  The 
operation  lasted  thirty  minutes.  Deep  collapse  followed,  in  which  the  patient  died 
twelve  hours  after  the  operation. 

Very  likely  an  early  operation  would  have  been  followed  by  a  better 
result. 

Case  II. — Philippine  Pahler,  aged  thirty-five.  Pyloric  cancer  of  stomach.  Febru- 
ary 18,  1886. — Probatory  abdominal  incision  at  the  German  Hospital,  with  a  view  to 
possible  resection  of  the  pylorus.  The  extension  of  the  disease  to  the  retro-peritoneal 
glands,  the  pancreas,  and  omentum  put  the  contemplated  step  out  of  question,  where- 
fore the  incision  was  closed.  March  11th. — Patient  discharged  with  firmly  healed 
wound. 

Case  III. — Albert  Schroeder,  painter,  aged  thirty.  Large  retro-peritoneal  tumor 
located  behind  hepatic  flexure  of  colon,  causing  intestinal  stenosis.  August  5,  188S. — 
Probatory  incision  at  the  German  Hospital  established  the  fact  of  the  inoperability  of 
the  swelling — a  sarcoma  of  the  mesocolic  glands.  Closure  of  wound.  August  9th. — 
Patient  died  in  collapse. 

h.  Abdominal  Tumors : 

(a)  GrEzsTEKAL  Remakks. — Avoidance  of  infection  from  without  by  scru- 
pulous cleansing  and  disinfection  of  hands,  instruments,  sponges,  and  other 
19 


13J: 


RULES  OF  ASEPTIC    AND  ANTISEPTIC  SURGERY. 


Fig.  112. — Ascites  and  ovarian  tumor.  Patient 
ready  for  operation  in  the  lateral  posture. 
Case  of  Dr.  W.  L.  Estes,  of  Bethlehem,  Pa. 


iiteusils  should  render  nuuecessary  the  application  to  the  peritoneal  cavity  of 

disinfectant  lotions,  which,  by  their  corrosive  properties,  may  produce  mischief. 

The  usual  measures  adopted  for  protecting  the  body  of  the  j)atient  against 

wetting  and  undue  cooling  off,  as  the  wrapping  up  of  the  extremities  in 

flannels,  and  the  spreading  of  rubber  cloths  over 
the  trunk  and  lower  limbs,  leaving  exposed  noth- 
ing but  the  abdomen,  demand  special  care  and 
attention.     Excessive  loss  of  dody  heat  is  a  great 

factor  in  determining 
collapse,  and  should  he 
guarded  against  most 
sedulously. 

The  principle  of  non- 
exposure  applies  equally 
to  the  contents  of  the 
abdominal  cavity.    The 
greater  the  incision,  the 
more  attention  must  be  paid  to  the 
non-exposure  of  the  intestines.  Hot, 
flat  sponges  or  towels  should   hide 
from    view    everything   except    the 
very  spot  subjected  to  surgical  ma- 
nipulation. 

The  use  of  the  spray  apparatus  during  abdominal  operations  is  harmless, 
but  unnecessary.  Certainly  it  forms  a  very  objectionable  feature  of  the 
original  Listerian  method, 

and  has  been  abandoned  --N  / 

in  general  as  well  as  ab- 
dominal surgery  by  most 
operators.  The  author  has 
not  used  the  spray  appa- 
ratus since  1881. 

The  control  of  haemor- 
rhage is  of  the  utmost 
importance  to  the  success 
of  abdominal  operations. 
This  and  the  former  re- 
quirements can  be  best 
fulfilled  by  an  intelligent 
observance  of  the  rules  laid 
down  in  the  paragraphs  on 
the  technique  of  surgical 
dissection  and  the  removal 
of  tumors.  The  principles 
there  explained  remain  unchanged,  their  application  to  abdominal  tumors 
only  being  somewhat  modified  by  the  peculiarities  of  the  locality. 


Fig.  113. — Protection  of  the  intestines  by  flat  sponges 
arranged  about  the  tumor. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         135 

An  ample  incision  is  the  first  condition  of  the  safe  removal  of  an  abdomi- 
nal tumor.  Wlieu  ti  unilocular,  nou-adherent  cyst  is  to  be  exsected,  a  small 
incision  will  be  ample,  because  the  cyst,  however  large,  can  be  emptied  by 
tapping,  and  is  thus  reduced  to  the  elongated  proportions  of  a  flat  band, 
which  can  be  extracted  through  the  small  incision  without  much  force  until 
the  pedicle  comes  in  view. 

Multilocular  cysts  that  can  not  be  emptied  readily,  or  solid  tumors,  or 
growths  with  many  adhesions,  must  be  freely  exposed,  to  enable  the  sur- 


Fia.  114. — Protection  of  the  intestines  in  ovariotomy  by  hot  towels. 


geon  to  see  what  is  to  be  done.  Accidental  laceration  of  the  gut,  bladder, 
or  large  veins  will  not  easily  occur  while  the  adhesions  binding  the  tumor 
to  these  organs  are  exposed  to  view. 

Disregard  of  this  plain  and  rational  rule  is  the  cause  of  many  an  accident 
and  mishap  that  might  be  easily  avoided  otherwise. 

Note. — However  important  the  incision  and  final  suture  of  the  abdominal  walls  may  be,  it 
must  not  be  forgotten  that  they  do  not  represent  the  critical  part  of  most  abdominal  operations. 
The  abdominal  incision,  being  a  preliminary  measure,  should  not  occupy  too  much  time.  Of 
course,  it  must  be  done  lege  artis,  but  with  expedition.  Bleeding  vessels  need  not  be  tied  here, 
as  the  pressure  of  the  hemostatic  forceps,  exerted  for  ten  or  fifteen  luiuutes,  will  effectually 
arrest  hfemorrhage.  Here,  as  elsewhere,  cutting  between  two  forceps  will  be  more  expeditious 
and  safer,  than  the  use  of  the  grooved  director. 

The  skillful  and  unstinted  use  of  mass  ligatures  by  means  of  Thiersch's 
spindle  apparatus  will  render  the  dissection  even  of  extensively  adherent 
abdominal  tumors  remarkably  bloodless  and  safe.  Strong  catgut  is  prefer- 
able to  silk,  as  the  latter  is  known  to  have  been  the  cause  of  suppuration  in 
a  good  many  cases,  although  the  silk  was  prepared  in  a  seemingly  proper 
fashion.  Extensive  masses  of  tissue,  especially  if  their  shape  approaches 
that  of  a  membrane,  should  not  be  included  in  a  single  ligature,  as  they  are 
very  ajjt  to  slip  at  the  edges.  It  is  safer  to  divide  them  into  a  number  of 
smaller  portions  which  should  be  separately  tied.  This  rule  apjDlies  to  the 
omentum  especially. 


130  EULES  OF   ASEPTIC   AND   ANTISEPTIC  SURGEEY. 

Adhesions  or  pedicles  of  ti  more  cylindrical  shape  can  be  safely  tied  in 
one  mass  without  risking  the  slipping  of  the  ligature.  Every  mass  should 
be  included  in  two  ligatures,  between  wiiich  it  can  be  severed  with  the  knife 
or,  better,  the  thermo-cautery. 

Transfixion  of  pedicles  with  a  sharp  Peaslee's  needle  is  not  advisable,  as 
large  veins  passing  into  the  mass  may  thus  be  cut  open  and  cause  trouble- 
some ha?morrhage  from  a  point  not  included  in  the  ligature.  It  is  better  to 
use  a  blunt  instrument,  such  as  Thiersch's  spindle,  or  a  dressing  or  artery  for- 
ceps, which  will  pass  through  any  pedicle  easily  without  injuring  the  vessels. 

Where  the  adhesion  or  pedicle  is  too  short,  and  the  tumor  too  large,  to 
admit  of  easy  manipulation  under  the  guidance  of  the  eye,  the  use  of  a 
temporary  elastic  ligature,  with  or  without  preliminary  transfixion  to  pre- 
A^ent  slipping,  will  be  found  a  welcome  expedient.  To  this,  a  rather  stout, 
solid  band  of  {not  rotten)  pure  gum-elastic,  and  one  or  more  round  probe- 
23ointed  steel  needles  are  necessary.  The  pedicle  is  first  transfixed  singly 
or  crucially,  then  the  rubber  band  is  thrown  around  the  needles  beyond  the 
place  of  transfixion.  The  ends  of  the  tightened  rubber  are  crossed  and 
secured  at  the  crossing  by  a  stout  pedicle-clamp.  After  this  the  tiimor  can 
be  cut  away,  and  the  pedicle,  becoming  more  accessible,  can  be  divided  and 
tied  off  with  catgut  in  several  portions.  As  soon  as  this  is  done  the  clamp 
is  loosened,  the  rubber  is  removed,  and  the  tied-off  masses  are  trimmed  and 
seared  with  the  actual  cautery. 

Close  adJiesions  of  the  gut  require  special  care.  Recent  adhesions  are 
easily  separated  by  blunt  preparation,  but  cause  a  good  deal  of  oozing. 
Much  wiping  and  sponging  of  the  oozing  points  is  apt  to  prolong  haemor- 
rhage, for  reasons  explained  elsewhere.  It  is  better  to  cover  these  points 
with  a  flat  sponge,  and  to  let  them  alone  till  haemorrhage  ceases  spontane- 
ously. The  blood  that  found  its  way  into  the  abdomen  must  be  sponged 
out  at  the  final  toilet.  Old  adhesions  of  the  intestine  are  very  dense,  and 
efforts  at  their  blunt  separation  may  easily  lead  to  injury  of  the  gut.  Dis- 
section by  the  scal23el,  the  line  of  section  being  well  away  from  the  intes- 
tine, will  be  found  the  most  expeditious  mode  of  proceeding.  Spurting 
vessels  must  be  tied,  and  as  soon  as  the  adhesion  becomes  less  close  and 
the  formation  of  masses  by  blunt  separation  possible,  mass  ligatures  should 
be  applied. 

Forcible  blunt  preparation  in  the  vicinity  of  large  veins,  more,  especially 
of  the  large  plexus  regularly  encountered  in  the  bottom  of  the  small  pelvis 
near  the  uterus  and  its  adnexa,  is  hazardous,  on  account  of  the  haemorrhage 
often  caused  by  laceration  of  the  delicate  walls  of  these  vessels.  Careful 
isolation  and  double  deligation,  with  subsequent  cutting  between  the  liga- 
tures, are  the  best  safeguard  against  dangerous  haemorrhage. 

Blunt  dissection,  preferably  by  the  tips  of  the  fingers,  is,  however,  emi- 
nently proper  where  the  peritonaeum  is  to  be  stripped  up  from  underlying 
tissues.  It  is,  in  fact,  the  only  safe  way  of  separating  tumors  that  are 
located  between  the  folds  of  the  broad  ligament,  in  the  mesentery,  or  in 
any  ])ortion  of  the  retro-peritoneal  space. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        1?,7 

Exploratory  puncture  and  aspiration  of  exposed  abdominal  cysts  of  un- 
known contents  with  a  fine,  hollow  needle  is  very  advisable,  as  the  exact 
knowledge  of  the  nature  of  the  cystic  contents  may  materially  modify  sub- 
sequent steps  of  the  operation. 

If  the  cystic  fluid  be  bland,  its  escape  into  the  peritoneal  cavity  does  not 
signify  much,  i)rovided  that  careful  cleansing  be  employed  before  the  clos- 
ure of  the  wound.  But  when  the  cyst  contains  purulent  or  fetid  serum, 
accidental  soiling  of  the  peritonaeum  by  it  may  efEectually  destroy  all  chances 
of  recovery. 

Whenever  puncture  of  an  exposed  tumor  is  determined  on,  whether  by 
a  small  or  large-sized  instrument,  good  care  must  be  taken  to  prevent,  dur- 
ing and  after  the  act,  the  escape  of  cystic  fluid  through  the  puncture-hole 
into  the  abdominal  cavity.  To  do  this  it  is  necessary  to  surround  the 
needle  or  trocar  with  a  number  of  flat  sponges  laid  on  the  tumor.  As  soon 
as  the  piston  is  withdrawn  the  nature  of  the  fluids  appearing  in  the  barrel 
of  the  syringe  will  become  manifest.  If  it  be  clear  and  limpid,  no  further 
precaution  need  be  taken.  Should  the  fluid  appear  to  be  turbid,  or  mani- 
festly purulent,  the  barrel  should  be  emptied  and  refilled  and  emptied  again, 
until  the  tension  of  the  sac  becomes  so  far  reduced,  that  its  transfixed  portion 
may  be  raised  in  a  fold  and  secured  by  a  large  clamp.  The  sponges  used 
for  this  step  of  the  operation  should  be  at  once  discarded. 

To  prevent  laceration  of  the  sac  or  capsule,  the  utmost  gentleness  and 
care  should  be  practiced  in  handling  the  tumor.  The  use  of  sharp  re- 
tractors and  vulsellum  forceps,  or  forcible  traction  with  or  without  blunt 
force  of  any  kind,  are  extremely  ill-advised.  Not  only  may  the  sac  be 
torn,  but  large  veins  spread  out  over  the  surface  of  the  tumor  may  be  in- 
jured, and  give  rise  to  uncontrollable  haemorrhage.  The  aperture  of  a  torn 
vein  can  not  be  easily  occluded  by  any  kinds  of  artery-clamp,  first,  because 
of  its  irregular  shape  and  extension,  and  principally  because  the  tension  of 
the  capsule  of  a  solid  tumor  precludes  the  formation  of  a  fold  that  could  be 
conveniently  grasped. 

Note. — The  author  recalls  an  instance  witnessed  by  him  where,  during  the  removal  of  a 
large  uterine  growth  through  an  inadequate  incision,  sharp  retractors  were  used  in  forcibly 
developing  the  mass  from  the  abdominal  cavity.  Several  large  veins  being  torn,  profuse  hiem- 
orrhage  set  in.  The  incision  was  somewhat,  but  still  insufficiently,  enlarged,  and,  more  force 
being  applied,  the  tumor  was  iinally  brought  out  of  the  abdomen.  But  very  soon  it  became  evi- 
dent that,  in  consequence  of  the  forcible  manipulation,  the  transverse  colon,  which  was  closely 
adherent  to  the  posterior  aspect  of  the  tumor,  had  been  extensively  torn.  Enterorrhaphy  did  not 
save  the  patient's  life,  which  was  forfeited  by  the  injudicious  management  induced  by  super- 
stitious fear  of  a  "  large  "  abdominal  incision. 

The  tenet  of  making  small  incisions  for  the  removal  of  abdominal  tumors 
had  its  origin  in  the  justified  disinclination  to  expose  a  large  peritoneal  sur- 
face to  the  contaminating  and  refrigerating  effect  of  the  atmospheric  air. 
And  unnecessarily  long  incisions  are  certainly  to  be  avoided.  But  the  sur- 
geon's discretion  must  decide  the  question  of  the  size  of  the  incision,  the 
principle  of  safe  dissection  under  the  guidance  of  the  eye  being  herein  of 
the  first  importance. 


138  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Undue  cooling  off  of  the  peritonaeum  is  a  very  undesirable  thing,  on 
account  of  the  collapse  it  may  induce  ;  therefore,  all  portions  of  the  abdomi- 
nal organs  that  are  not  actually  under  dissection  should  be  carefully  covered 
up  by  large  flat  sponges  or  clean  towels  wrung  out  of  hot  Thiersch's  solution. 

Note. — To  always  have  a  sufficient  supply  of  warm  sponges  and  towels,  the  following 
arrangement  will  be  found  convenient :  A  tin  pan  or  basin,  containing  the  sponges  or  towels 
immersed  in  Thiersch's  solution,  is  rested  on  the  tops  of  two  clean  bricks  stood  on  edge.  A 
blazing  alcohol-lamp  is  placed  between  the  bricks  and  underneath  the  vessel,  which,  being  cov- 
ered with  another  pan,  will  preserve  unchanged  the  temperature  of  its  contents.  For  larger 
operations,  three  or  four  similarly  prepared  pans  can  be  conveniently  arranged  on  a  separate 
table. 

"Whenever  a  stout  adhesion  or  a  pedicle  is  deligated  and  cut  through, 
it  should  be  dropped  back  into  its  natural  position,  where  it  should  be 
inspected  for  a  short  while  to  see  whether  haemorrhage  is  thoroughly  con- 
trolled by  the  ligature.  Oozing  points  should  be  touched  with  the  thermo- 
cautery, but  care  must  be  taken  not  to  go  too  near  the  ligature,  for  fear  of 
burning  it. 

Oozing  points  located  on  the  gut  should  never  be  touched  with  the 
thermo-cautery. 

It  is  best  not  to  tap  at  all  dermoid  cysts  or  tumors  containing  clearly 
septic  fluid,  as  the  integrity  of  the  cyst-wall  is  the  only  guarantee  of  pre- 
venting contamination  of  the  abdominal  cavity  by  cystic  fluids.  Eather 
increase  the  external  incision,  and  remove  the  tumor  intact. 

The  relations  of  the  bladder  to  the  tumor  should  be  carefully  considered. 
Greig  Smith  advises  not  to  emijty  the  Madder  hefore  oiieration,  and  it  is 
undeniable  that  a  full  bladder  can  not  be  well  overlooked  or  injured.  In- 
jury to  an  empty  and  collapsed  bladder,  on  the  other  hand,  has  repeatedly 
occurred  in  the  presence  of  abnormal  adhesions  of  the  organ  to  the  tumor. 
To  further  ascertain  the  extent  of  adhesions  of  the  bladder,  the  introduc- 
tion and  manipulation  of  a  solid  male  urethral  sound  will  be  found  very 
useful. 

XoTE. — Catheterism  should  be  done,  if  possible,  by  a  person  not  employed  about  the 
wound,  or,  if  this  be  not  feasible,  careful  cleansing  and  disinfection  of  the  hands  should  follow  it. 

After  the  removal  of  the  tumor,  the  toilet  or  cleansing  of  the  abdominal 
cavity  has  to  be  attended  to.  Sponges  attached  to  long  handles  are  very 
convenient  for  this  purpose.  With  them  first  the  lumbar,  then  the  vesico- 
uterine recesses,  finally  the  utero-rectal  or  Douglas's  pouch,  are  to  be  thor- 
oughly cleansed  and  dried. 

In  the  presence  of  large  denuded  surfaces  lacking  peritoneal  investment, 
a  glass  or  hard-rubber  drainage-tube  is  to  be  inserted  into  the  bottom  of 
the  small  pelvis.  It  can  be  brought  out  through  a  counter-opening  made 
into  the  vagina  from  Douglas's  pouch,  or  through  the  lower  angle  of  the 
abdominal  incision. 

In  the  former  case,  the  external  end  of  the  tube  projecting  into  the 
vagina  or  in  the  vulva  must  be  wrapped  in  a  packing  of  iodoformized 
gauze,  which  ought  to  be  changed  whenever  it  gets  saturated.     When  the 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.         139 

tube  is  brought  out  through  the  abdominal  incision,  its  outer  end  must  be 
so  dressed  as  to  bo  easily  accessible.  Every  hour  the  serum  collecting  in 
its  bottom  should  be  exhausted  with  a  pad  of  absorbent  berated  cotton  fixed 
to  a  handle,  or  with  a  long-nozzled  syringe.  In  the  intervals  the  tube  should 
be  covered  with  a  moist  pad  of  sublimated  gauze.  As  the  serum  diminishes, 
this  process  is  gone  through  with  at  longer  intervals.  As  soon  as  the  tube 
remains  dry  for  several  hours,  generally  about  the  third  day,  it  can  be  with- 
drawn. 

XotE. — Miculicz  has  successfully  substituted  for  the  drainage-tube  a  loose  packing  and  fillet 
of  iodoformized  gauze,  brought  out  through  an  angle  of  the  wound.  The  exsiccation  of  the  secre- 
tions by  this  arrangement  is  certainly  very  effective,  as  seen  in  several  cases  reported  by  Dr.  F. 
Lange.     The  fillet  should  be  removed  on  the  third  or  fourth  day. 

The  closure  of  the  abdominal  wound  should  le  done  as  rapidly  as  thor- 
oughness will  permit,  simplicity  and  solidity  of  the  suture  being  the  main 
desiderata. 

A  Peaslee's  needle  is  thrust  on  one  side  through  the  entire  thickness  of 
the  abdominal  wall,  including  the  peritonaeum,  and  is  brought  out  in  a 
similar  manner  on  the  other.  The  points  of  entrance  and  emergence  should 
be  at  least  two  inches  from  the  edges  of  the  wound.  A  piece  of  well-disin- 
fected silver  wire  or  stout  silk-worm  gut,  armed  with  a  quill,  or  a  leaden 
button  and  shot,  is  threaded  through  the  eye  of  the  needle.  This  is  then 
withdrawn,  brinaing  out  the  end  of   the   thread  from   one   side   of  the; 


Fig.  115. — Completed  quilled  suture  of  abdominal  incision. 


wound  to  the  other,  where  it  is  temporarily  secured  by  an  artery  forceps. 
Three,  four,  or  more  retentive  sutures  of  this  kind  are  passed  at  intervals  of 
about  an  inch,  until  the  entire  length  of  the  wound  is  covered  by  them. 

Note. — "While  the  stitches  are  being  passed,  a  flat  sponge  should  be  kept  spread  over  the 
intestines  to  receive  the  blood  escaping  from  the  stitch-holes. 

If  the  patient's  condition  be  good,  the  peritonseum  may  be  separately  united  by  a  row  of 
catgut  sutures  placed  between  the  silver  or  silk-worm  gut  stitches.     But  this  is  not  essential. 


140 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fi(3.  116. — Completed  plate  and  shot  suture  of  abdominal  wounds. 


After  the  withdrawal  of  the  flat  sponge,  and  a  final  cleansing  of  the  peri- 
tonaeum by  sponges  fixed  to  long  handles,  a  quill  is  applied  to  the  unarmed 

end  of  the  thread,  and 
is  tightened  until  the 
edges  of  the  incision 
are  raised  in  the  shape 
of  a  low  ridge.  Or, 
if  lead  buttons  are  to  be 
used,  one  of  these  is 
slipped  on  the  thread 
with  a  perforated  shot, 
the  thread  is  tight- 
ened, and  the  shot  is 
pinched.  After  this, 
a  sufficient  number  of 
exact  "  sutures  of  co- 
aptation," made  of  fine 
catgut,  secure  the  edges 
of  the  incision.  (Figs. 
115  and  116). 

The  dressings  con- 
sist of  a  few  strips  of  iodoform-gauze,  and  an  ample  compress  of  sublimated 
gauze  over  it,  all  snugly  fastened  by  several  strips  of  adhesive  plaster  and  a 
broad  flannel  or  gauze  bandage. 

On  from  the  eighth  to  the  tenth  day  the  dressings  are  changed,  and  the 
retentive  sutures  are  removed  ;  but  the  bandage  must  be  worn  for  some 
time  to  serve  as  a  support  to  the  fresh  cicatrix. 
{b)  Special  Obseevations  : 

a.  Ovarian  Tumors.  —  Probatory  puncture  of  an  abdominal  tumor 
through  the  walls  of  the  belly  is  not  an  indifferent  matter.  If  the  tumor  be 
cystic,  and  its  wall  very  tense,  escape  of  a  limited  quantity  of  cystic  contents 
is  unavoidable.  Bland  and  very  thin  contents  may  escape  in  large  quantities 
without  causing  irritation.  A  large  number  of  cases  are  on  record  in  which 
probatory  puncture  of  cysts  of  the  broad  ligament  was  followed  by  cure. 

Case. — Mrs.  Francisca  N.,  liquor-dealer's  wife,  aged  thirty-four,  was  tapped, 
August  31,  1877,  for  a  large  abdominal  cyst.  About  a  gallon  of  fluid,  characteristic  of 
a  cyst  of  the  broad  ligament,  was  removed,  but  a  considerable  quantity  was  left  behind. 
In  a  short  time  the  flabby,  fluctuating  swelling  disappeared  entirely,  and  the  woman 
remained  free  from  any  further  trouble. 

Escape  of  minute  portions  of  purulent  cyst-fluid  is  apt  to  cause  circum- 
scribed peritonitis,  resulting  in  more  or  less  extensive  adhesions.  Larger 
quantities  of  septic  matter,  tliat  find  their  way  into  the  peritoneal  cavity, 
may  produce  fatal  purulent  peritonitis. 

The  preparations,  with  a  view  to  the  aseptic  performance  of  exploratory 
or  evacuating  puncture,  must  be  very  thorough,  as  the  use  of  an  unclean 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.         141 

needle  or  trocar  may  be  tlie  source  of  peritonitis  or  suppuration  of  the  sac. 
The  hollow  needle  or  trocar  to  be  used  must  be  sterilized  either  by  boiling 
for  an  hour  in  a  five-per-cent  solution  of  carbolic  acid,  or  by  incandescence 
in  the  alcohol-flame. 

When  an  exposed  cyst  is  to  be  tapped  or  emptied  by  incision,  the  patient 
should  be  turned  over  on  her  side.  An  assistant  should  prevent  the  escape 
of  gut ;  another  one  should  surround  the  place  of  tapping  with  a  circle  of 
sponges  to  receive  fluid  that  may  escape  alongside  of  the  instrument.  Tait's 
trocar  is,  on  account  of  its  simplicity,  the  best  one  of  all  instruments  devised 
for  evacuating  cysts. 

As  soon  as  the  cyst  begins  to  collapse,  its  folds  should  be  taken  up  with 
large  clamps.  The  empty  cyst  is  then  withdrawn  to  the  pedicle,  which  is 
tied  in  one  or  more  portions  and  cut  off. 

Case  I. — Mrs.  Dorothy  Grunewald,  aged  sixty-one,  multipara.  Unilocular  cyst  of 
the  left  ovary.  December  19,  1882. — Ovariotomy.  External  incision  four  inches  long. 
Cyst  presenting,  patient  was  brought  in  lateral  position.  Tapping,  evacuation,  and 
extraction.  Eather  stout  pedicle  transfixed  with  thumb- forceps,  and  tied  in  four  por- 
tions, then  cut  off  and  dropped  back  into  the  abdomen.  Uninterrupted  recovery. 
January  4,  1883. — Discharged  cured. 

Multilocular  cysts  can  be  best  emptied  by  making  a  free  incision  through 
their  presenting  part,  through  which  the  hand  can  be  carried  within  the 
tumor  to  break  up  intervening  septa.  All  this  should  be  done  extra-abdom- 
inally  if  possible. 

When  a  cyst  is  found  extensively  adherent,  its  contents  should  be  care- 
fully mopped  out  with  a  sponge,  and  the  interior  of  the  sac  should  be  dis- 
infected while  the  patient  is  in  the  lateral  posture.  After  this  a  large  sponge 
is  thrust  into  and  left  within  the  cavity  until  the  cyst  is  dissected  out. 

Case  II.— Miss  Lucretia  Bernard,  aged  seventy-two,  virgin.  Very  large  multilocu- 
lar ovarian  cyst  of  the  right  side,  causing  intense  dyspnoea.  August  8,  1881. — Punct- 
ure and  partial  evacuation  at  Mount  Sinai  Hospital,  resulting  in  marked  relief  of  the 
dyspnoea.  August  10th. — Fever  set  in,  with  some  abdominal  tenderness,  and  suppura- 
tion of  the  cyst  was  apprehended.  August  13th. — Ovariotomy.  Incision  twelve  inches 
long.  Broad,  recent  adhesion  of  the  sac  to  the  anterior  abdominal  wall  severed  by 
blunt  preparation.  Patient  being  brought  into  the  side  position,  the  cyst  was  first 
tapped,  then  incised,  and  its  volume  was  much  reduced  by  breaking  down  septa  by  the 
hand.  Some  hemorrhage  occurring,  a  large  sponge  was  thrust  into  the  sac,  and  the 
patient  was  returned  to  the  supine  position.  A  number  of  adhesions  to  the  right  side 
of  the  parietal  peritonaeum  and  ascending  colon  were  divided  between  several  double 
mass  ligatures  of  silk.  Short  pedicle  was  similarly  secured.  Toilet  of  peritoneum ; 
closure  of  incision.  Moderate  elevations  of  the  temperature.  Uninterrupted  healing 
of  wound.  Noxernber  15th. — Abscess  of  right  groin  was  incised.  Three  silk  ligatures 
were  discharged.  August  11,  1882. — Patient  died  of  an  intercurrent  disease  not  con- 
nected with  ovariotomy. 

Case   III. — Mrs.  Lena   Dochtermann,    aged  thirty-nine,  multipara.      Very  large 

multilocular  cyst  of  right  ovary.      General    condition  very  poor;  chronic  bronchial 

catarrh  and  chronic  enteritis,  with  diarrhoea,  ascites,  and  anasarca.     April  19,  1886. — 

Ovariotomy.    Extensive  adhesions  of  cyst  to  anterior  and  lateral  parietes ;  to  transverse 

20 


142 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


colon,  omentum,  and  the  bladder.  A  large  number  of  mass  ligatures  were  made, 
riffimorrhage  insignificant.  Duration  of  operation  two  hours  and  a  half.  Patient  died 
in  collapse  seven  hoars  after  the  completion  of  the  operation,  temperature  remaining 
subnormal  to  the  last. 

Cysts  of  the  broad  ligament  generally  present  great  difficulties  on  account 
of  their  situation  between  the  peritoneal  folds  of  the  ligament.  If  they 
extend  low  down  into  the  small  pelvis,  their  dissection  is  occasionally  im- 
practicable, and  always  very  difficult.  The  utmost  circumspection  and  care 
must  be  exercised  not  to  provoke  haemorrhage  by  injuring  large  veins  in  the 
bottom  of  the  wound,  and  all  adhesions,  not  yielding  to  gentle  blunt  dissec- 
tion with  the  fingers,  must  be  fashioned  into  suitable  masses,  doubly  tied 
with  Thiersch's  spindles,  and  then  divided.  In  cases  baffling  the  skill  or 
enterprise  of  the  surgeon,  the  sac  should  be  properly  trimmed  and  stitched 
to  the  skin,  so  as  to  convert  it,  if  possible,  into  an  extra-peritoneal  recess. 
Drainage  of  the  sac  is  indispensable. 

Case  IV. — ]yrs.  Ethel  D.,  aged  twenty-one,  nullipara.  Eather  immovable  cyst  of 
the  right  broad  ligament  of  the  size  of  a  child's  head.  Apy'il  6,  1887. — Ovariotomy. 
Incision  five  inches  long.  The  cyst  had  dissected  its  way  out  from  between  the  folds 
of  the  broad  ligament,  and  had  pushed  away  the  parietal  peritonaeum  of  the  anterior 
abdominal  wall  on  the  right  side  to  such  an  extent  as  to  remain  entirely  extra-peritoneal. 
The  sac  was  tapped  and  emptied,  then  it  was  easily  separated  from  its  attachments  by 
bluni  preparation.  About  one  fourth  of  a  square  foot  of  peritonaeum  was  detached. 
Finally,  the  pedicle  was  reached,  secured  in  three  ligatures  carried  through  by  means 
of  Thiersch's  spindles,  tied,  and  cut  off.  The  cavity  was  mopped  out  with  corrosive- 
sublimate  lotion,  drained  by  two  ordinary  rub- 
ber tubes,  and  the  external  wound  united  and 
dressed  in  the  nsual  manner.  April  7th. — 
Nothing  alarming  had  occurred,  the  tempera- 
ture ranging  about  99°  Fahr.  Ai^ril  8tli. — 
Temperature  101*5°  Fahr.,  with  a  good  deal  of 
tympanites  and  dyspnoea.  Pulse  of  varying  in- 
tensity and  rhythm,  about  125  beats  per  minute, 
and  rather  weak.  The  outer  bandage  had  to  be 
loosened,  and  energetic  stimulation  by  hourly 
enemata,  consisting  of  one  ounce  of  brandy  and 
two  ounces  of  warm  vrater,  were  administered, 
till  the  pulse  became  decidedly  fuller  and  more 
regular.  April  10th. — Some  flatus  passed  spon- 
taneously, the  meteorism  diminished  markedly, 
and  the  temperature  fell  to  the  normal  standard. 
April  11th. — Patient  consumed  a  few  oysters 
and  a  little  champagne,  her  nourishment  hav- 
ing consisted  until  then  of  milk  and  lime-water. 
On  the  same  date  slight  uterine  and  vesical 
hfemon-hage  was  noted.  The  former  may  have 
been  dependent  upon  subinvolution  remaining  behind  after  a  recent  miscarriage  ;  the 
vesical  hseinorrliage  seems  to  have  been  due  to  detachment  of  the  superior  and  lateral 
vesical  wall  during  dissection.  April  13th. — A  saline  laxative  was  administered,  caus- 
ing some  nausea  and  vomiting  with  a  good  deal  of  griping,  but  resulting  in  three  copi- 


FiG.  117. — Dia^am  of  cyst  of  the  broad 
ligament.     (Case  IV.) 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.         143 


ous  stools.  The  same  day  the  drainage-tubes  were  shortened.  The  wound  was  found 
healed  by  adhesion  except  where  the  tubes  lay.  Three  of  the  plate  and  shot  sutures 
were  also  removed,  and  two  were  left  behind.  The  catgut  sutures  had  been  all  ab- 
sorbed. April  ISth.— The  tubes  were  entirely  withdrawn  and  remaining  sutures 
removed.  April  20th. — The  patient  left  tlie  bed  the  first  time.  April  S5th.—The 
wound  was  entirely  healed.     (Fig.  117). 

It  seems  that  the  extensive  detachment  of  the  peritonaBum  from  its 
nutrient  vessels  led  to  a  grave  disturbance  of  its  circulation,  and  perhaps  to 
partial  {asejoUc)  necrosis.  An  adhesive  peritonitis  of  the  intestinal  invest- 
ment apposed  to  the  denuded  parietal  peritoneum  was  set  up,  causing 
paralysis  of  the  muscular  layer  of  the  gut  with  meteorism.  As  soon  as  the 
devitalized  parts  of  the  peritonseum  were  enveloped  by  fresh  exudations,  the 
irritation  ceased. 

p.  Supra-vagmal  hysterectomy  for  large  myo-fibroma  of  the  uterus  may 
be  indicated  either  by  profuse  loss  of  blood  at  the  menstrual  epoch,  or  by 
other  causes  rendering  the  patient's  life  unendurable.  An  operation  should 
be  determined  on  only,  after  a  faithful  trial  of  less  incisive  remedies  known 
to  induce  involution  of  uterine  fibromata,  has  plainly  failed  to  give  relief. 

The  jDreparations  for  the  operation  are  to  be  made  with  all  possible  care, 
directed  to  the  avoidance  of  septic  infection.  Haemorrhage  is  to  be  pre- 
vented by  the  •application  of  single  or  double  mass  ligatures  to  the  uterine 
adnexa  on  both  sides 
of  the  uterus,  and 
a  stout  elastic  cord 
to  the  cervix.  Un- 
der favorable  condi- 
tions (that  is,  when 
the  cervix  forms  a 
slender  pedicle  to  the 
otherwise  movable 
womb),  the  applica- 
tion of  double  liga- 
tures can  be  obviated 
by   cutting    off    the 

blood-supply  of  the  organ  from  all  sides  by  two  continuous  lines  of  mass 
ligatures  converging  from  the  free  margin  of  the  adnexa  toward  the  cervix. 
A  suitable-sized  mass  is  first  formed  at  the  margin  of  the  broad  ligament  by 
means  of  Thiersch's  spindle,  and  is  tied  off  with  strong  catgut  or  silk.  A 
second  mass  adjoining  the  first  one  is  now  isolated,  and  the  thread  being 
carried  around  it  and  back  through  the  aperture  made  for  the  applica- 
tion of  the  first  ligature,  is  firmly  knotted.  A  third  mass  is  isolated  by 
Thiersch's  spindle,  and  the  thread  is  carried  back  through  the  hole  made 
for  the  isolation  of  the  adjacent  mass,  and  the  application  of  the  preceding 
hgature.  Thus  the  cervix  will  be  soon  reached.  While  an  assistant  raises 
the  tumor  well  above  the  pelvis,  an  elastic  ligature  is  thrown  around  the 
elongated  cervix ;  being  tightened,  it  is  secured  by  a  stout  pedicle-clamp. 


Fig.  118. — Diagram  showing  the  arrangement  of  mass  ligatures  in 
supra- vaginal  hysterectomj'. 


144  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Tliis  step  will  have  completed  the  isolation  of  the  uterus,  which  can  be  now 
exsected  without  loss  of  blood,  the  line  of  section  being  carried  just  outside 
of  the  chain  of  ligatures.     (Fig.  118.) 

The  uterine  stump  must  not  be  cut  oif  too  short,  as  it  is  desirable  to 
retain  sufficient  material  for  covering  up  its  raw  surface  with  peritonaeum. 
The  cervical  canal  is  to  be  burned  out  thoroughly  with  the  thermo-cautery, 
to  destroy  any  septic  material  contained  in  it.  After  this,  the  cut  surface 
of  the  uterine  stump  is  hollowed  out  with  the  scalpel  in  the  shape  of  a  cup, 
its  center  being  located  in  the  cervical  canal.  This  is  done  until  the  edges 
of  the  cut  can  be  folded  upon  each  other,  when  they  are  united  with  a 
sufficient  number  of  deep,  intermediate,  and  superficial  catgut  sutures. 
The  deep  sutures  are  to  be  applied  with  a  large  curved  needle,  that  should  dip 
down  to  the  level  of  the  elastic  ligature.     The  intermediate  sutures  should 

reach  to  about  one  half  of  the  depth  of  the  stump ; 
the  superficial  stitches  are  to  hold  together  the 
peritoneum.     Thus  exact  coaptation  of  the  entire 
cut  surface  of  the  uterine  stump  is  brought  about, 
and  it  serves  two  good  purposes  :  First,  the  elas- 
tic ligature  can  be  removed  without  fear  of  pro- 
FiG.  119.— Suture  of  uterine    fuse  haemorrhage.   Any  oozing  between  the  stitches 
?yTe'rectmy.Tcwl3     ^an  be  controlled  by  'sponge  pressure  till  a  clot  is 
formed  within  the  wound.     The  second  advantage 
is  the  exclusion  of  all  communication  between  the  vagina  and  cervix  on  one 
side,  and  the  peritoneal  cavity  on  the  other.     (Fig.  119). 

Where  the  pedicle  is  short  and  very  stout,  slij)ping  of  the  elastic  liga- 
ture must  be  prevented  by  crucial  transfixion  of  the  cervix  with  a  pair  of 
large  and  well-disinfected  shawl-pins.  These  can  be  removed,  together 
with  the  rubber  cord,  after  the  completion  of  the  suture  of  the  stump. 

In  the  j)resence  of  adhesions,  or  a  broad  imjalantation  of  the  myoma  into 
the  decider  parts  of  the  pelvis,  the  same  rules  of  dissection  are  to  be  heeded 
that  have  been  elucidated  in  a  former  paragraph  relating  to  abdominal  tumors. 
The  author's  only  case  of  supra-vaginal  hysterectomy  ended  fatally  by 
septicaemia.  The  sources  of  infection  were  presumably  the  sponges,  man- 
aged by  two  raw  members  of  the  training-school  for  nurses  at  Mount  Sinai 
Hospital. 

Case. — Mrs.  S.  Levy,  aged  thirty-three,  multipara.  Very  large  fibro-myoma  of  the 
corpus  uteri.  Severe  metrorrliagia  at  each  menstruation,  with  increasing  anaamia  and 
great  helplessness  from  the  size  of  the  tumor.  June  7,  1883. — Hysterectomy  at  Mount 
Sinai  Hospital.  Incision  six  inches  long.  Easy  deligation  of  adnexa  in  two  rows  of 
mass  ligatures  ;  elastic  ligature  of  cervix ;  ablation  of  the  tumor  and  adnexa.  Searing 
of  tlie  surface  of  the  small  stump  by  thermo-cautery.  The  smallness  of  the  stump 
induced  the  author  to  treat  it  like  an  ovarian  pedicle,  and  it  was  replaced  in  the  abdomi- 
nal cavity  after  securing  of  the  elastic  ligature  by  a  knot  of  strong  silk.  Hardly  any 
blood  was  lost,  and  a  smooth  course  of  healing  was  expected.  But  all  hopes  were 
shattered  by  the  development  of  septic  symptoms  in  the  night  following  the  operation. 
June  8th. — High  fever,  retching,  and  sharp  abdominal  pain  were  present,  but  no  signs 


SPECIAL   APPLICATION   OF  THE  ASEPTIC   METHOD.         145 

of  peritonitis  could  be  made  out.  Twenty-nine  hours  after  tlie  operation  the  patient 
died  in  coma.  Post-mortem  examination  revealed  an  abscess  of  the  abdominal  wall  in 
the  line  of  suture,  and  a  grayish  discoloration  of  the  peritonaeum  near  the  elastic  liga- 
ture. A  few  drachms  of  turbid,  bloody  serum  were  found  in  Douglas's  pouch.  No 
sign  of  peritonitis. 

Investigation  showed  that  during  the  operation  tlie  management  of  the 
sponges  by  the  nurses  had  been  a  careless  one  ;  that  a  too  large  number  of 
persons  were  intrusted  with  the  care  of  the  sponges.  The  practical  out- 
come of  this  experience  was  the  order,  that  the  sponges  should  be  attended 
to  by  one  person  only,  and  that  this  person  should  always  be  the  most 
experienced  and  responsible  one  of  the  available  number. 

The  preceding  case  shows  that  fatal  septicemia  may  be  induced  by  infec- 
tion of  the  peritonaeum,  and  yet  purulent  peritonitis  may  be  absent.  Per- 
haps there  was  not  enough  time  for  the  development  of  peritonitis. 

Many  rcqndly  fatal  cases,  classed  hy  various  surgeons  under  the  heading 
of  '^  shocTc,^'  or  "  exhaustion,^^  ivould,  on  closer  iyiquiry,  turn  out  to  he  cases 
of  acute  septiccBmia. 

y.  Nephrectomy  hy  abdominal  section  is  clearly  Justified  in  cases  of  de- 
generated movable  kidney  when  the  urine  gives  sufficient  evidence  of  chronic 
pyonephrosis  .with  or  without  stone. 

Case. — Mrs.  S.  Weissenstein,  aged  forty-six.  Noticed  fourteen  years  ago  a  mova- 
ble painless  lump  in  her  right  hypocliondrium.  Since  about  nine  months  very  acute 
symptoms  of  cystic  trouble  set  in,  and  the  lump  became  larger  and  painful.  Constant 
desire  to  urinate,  continuous  fever,  with  occasional  rigors,  and  large  quantities  of  pus 
in  the  urine  brought  her  to  a  very  low  state.  A  smooth,  hard,  kidney-shaped  movable 
tumor  of  the  size  of  a  large  man's  fist  could  be  felt  in  the  right  hypochondriac  region. 
January  11,  1887. — Examination  under  chloroform.  The  left  hidney  could  not  he 
made  out  distinctly.  The  urine  was  scanty  and  acid,  amounting  to  about  twenty  ounces 
per  day,  of  the  consistency  of  cream,  and  contained  very  large  quantities  of  pus.  Janu- 
ary 15th. — Abdominal  nephrectomy  at  the  German  Hospital.  The  tumor  being  ex- 
posed, the  hand  was  slipped  into  the  left  lumbar  part  of  the  peritoneal  cavity,  when 
the  left  hidney  could  he  distinctly  felt.  After  this  the  peritonaeum  and  its  capsule  were 
split  along  the  whole  anterior  aspect  of  the  enlarged  kidney,  and  the  organ  was  easily 
peeled  out.  A  pedicle  was  formed  of  the  ureter  and  vessels,  and  was  tied  off  in  two 
masses.  After  the  removal  of  the  tumor,  the  large  retro-peritoneal  cavity  was  carefully 
mopped  out  and  loosely  packed  with  strips  of  iodoformed  gauze.  These  were  brought 
out  near  the  upper  angle  of  the  abdominal  wound.  The  edges  of  the  incision  through 
the  posterior  lamella  of  the  peritonaeum  and  the  renal  capsule  were  stitched  to  the 
peritoneal  lining  of  the  anterior  abdominal  wall.  The  outer  wound  was  united  in  the 
usual  way.  The  patient  lost  very  little  blood,  but  dui-ing  the  operation  threatening 
heart- weakness  necessitated  the  subcutaneous  exhibition  of  camphor  and  whisky.  She 
rallied  pretty  well,  and  passed  some  perfectly  clear  urine  shortly  after  the  operation. 
January  16th. — Temperature,  100°  Fahr.  Patient  cheerful,  and  suffering  very  little 
pain.  Urine  continues  clear  and  very  concentrated.  In  the  night  several  fainting- 
spells.  The  night  nurse  did  not  pay  sufficient  attention  to  tlie  patient,  who  died  in  a 
fit  of  syncope  early  in  the  morning  of  January  17th.  Post-mortem  examination  failed 
to  show  any  morbid  change  aside  from  the  abdominal  wound,  which  was  found  dry, 
and  just  as  fresh  as  at  the  time  of  the  operation.     With  more  untiring  stimulation,  the 


146  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

patient  might  have  survived.  The  enlarged  right  kidney  had  lost  its  textural  charac- 
ter, and  was  converted  into  an  irregular  sinuous  hag,  containing  six  uratic  stones  of 
various  sizes,  surrounded  by  a  quantity  of  pus. 

('.  Gastrostomy. — ImjmssaUe  cicatricial  stenosis  of  the  oesophagus  is  a 
very  strong  indication  for  the  establishment  of  a  gastric  fistula.  Threat- 
ening starvation  will  be  thus  averted,  and  an  opportunity  will  at  the  same 
time  be  created  for  attempting  retrograde  catheterism  of  the  oesophagus, 
which  may  succeed. 

Case. — Hedwig  Meyer,  aged  twenty-four.  Cicatricial  impassable  stricture  of  the 
oesophagus  twelve  inches  from  incisors,  caused  by  swallowing  pure  carbolic  acid. 
Liquids  only  could  be  swallowed,  with  frequent  regurgitations.  Extreme  emaciation. 
April  17,  1886. — Gastrostomy  at  the  German  Hospital.  Immediately  below  and  par- 
allel with  the  left  costal  arch,  an  incision  of  two  and  a  half  inches  exposed  the  perito- 
naeum. After  stanching  the  slight  haemorrhage,  the  peritonaeum  was  incised,  and 
tlie  edges  of  the  pei-itoneal  incision  were  taken  up  by  four  artery  forceps.  The  left 
lobe  of  the  liver  was  found  presenting.  This  being  pushed  aside,  the  anterior  wall  of 
the  empty  stomach  came  in  view,  and  was  withdrawn  from  the  wound  with  a  pair  of 
thumb-forceps.  The  cardiac  portion  of  the  organ  was  drawn  well  into  the  wound,  and 
was  transfixed  with  a  Peaslee's  needle  to  prevent  its  slipping  back.  The  peritoneal 
covering  of  the  stomach  was  stitched  to  the  everted  edges  of  the  parietal  peritonteum 
by  two  tiers  of  interrupted  silk  sutures.  The  artery  forceps  were  of  very  great  service 
in  securing  the  apposition  of  broad  peritoneal  surfaces.  The  external  wound  was 
packed  with  iodoformized  gauze,  and  dressed  antiseptically.  No  reaction  following, 
the  packing  was  removed  on  April  20th,  and  the  Peaslee's  needle  was  withdrawn. 
After  this  an  incision  one  half  inch  long  was  made  into  the  stomach,  and  a  short  piece 
of  stout  drainage-tube  snugly  fitting  into  the  aperture  was  placed  in  the  stomach,  and 
was  secured  from  slipping  in  by  a  large  safety-pin.  Its  opening  was  closed  by  a  cork 
stopper.  Previous  to  this  the  lips  of  the  mucous  membrane  were  stitched  to  the  outer 
skin.  From  this  date  on  daily  attempts  were  made  to  pass  the  stricture  with  a  sound, 
introduced  into  the  oesophagus  from  below,  through  the  gastric  wound.  May  13th. — 
Dr.  Bachmann,  the  house-surgeon,  succeeded  in  passing  from  below  an  elastic  catheter 
armed  with  a  mandrel  through  the  stricture.  Milk  injected  into  the  catheter  made  its 
appearance  in  the  fauces.  May  IJ^tTi. — A  small-sized  sound  was  passed  from  above. 
Alimentation  was  carried  on  both  artificially  through  the  drainage-tube  placed  in  the 
stomach,  and  by  the  mouth.  Gradually,  as  the  ability  to  swallow  sohds  returned,  more 
and  more  food  was  taken  by  the  mouth,  and  the  drainage-tube  was  withdrawn  from 
the  stomach.  The  gastric  fistula  closed  spontaneously  by  the  end  of  June.  August 
26th. — Patient  was  discharged,  with  directions  to  continue  the  use  of  the  oesophageal 
bougie. 

In  cases  of  cancer  of  the  (esophagus,  gastrostomy  does  not  yield  favorable 
results.  Of  six  cases,  mostly  men  past  middle  age,  and  all  presenting  the 
picture  of  more  or  less  extreme  emaciation,  five  died  in  a  few  (all  within 
twelve)  hours  after  the  operation.  The  slight  depression  of  the  heart's  action 
by  anaesthesia  was  sufficient  to  induce  fatal  collapse.  The  sixth  case  sur- 
vived the  operation  for  thirty-two  days,  but  was  losing  ground  steadily  m 
spite  of  artificial  feeding  by  the  tube  placed  in  the  stomach.  A  great  deal  of 
difficulty  was  experienced  in  this  case  on  account  of  the  considerable  leakage 
that  was  taking  place  alongside  of  the  tube.     Apparently  the  incision  had 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.        147 

been  made  too  large,  and  gastric  juice  was  escaping  in  varying  quantities 
into  the  dressings.  Tiie  gradual  emaciation  and  Unal  dissolution  were  in  a 
great  measure  due  to  this  constant  loss  of  albuminoid  substances. 

The  outer  dressings  of  a  gastrostomy  wound  are  arranged  in  the  follow- 
ing manner  :  A  split  compress  of  iodoformized  gauze,  similar  to  that  used 
in  tracheotomy  dressings,  is  slipj)ed  in  under  the  safety-pin  holding  the 
drainage-tube,  and  is  arranged  around  the  same.  A  piece  of  rubber  tissue, 
or  sheet  rubber,  somewhat  larger  than  the  gauze  compress,  is  provided  with 
a  not  too  large  slit  in  its  middle,  which  then  is  also  slipped  on  the  end  of 
the  tube  by  being  jiassed  first  over  one,  then  over  the  other  end  of  the  pin. 
The  rubber  should  fit  snugly  to  the  tube.  Over  this  is  laid  a  succession 
of  two  or  more  sublimate-gauze  compresses  of  increasing  size,  each  pro- 
vided with  a  slit  for  the  passage  of  the  corked-uji  end  of  the  rubber  tube. 
The  safety-pin,  which  Avas  underpadded  by  the  iodoformed  gauze  and  rub- 
ber sheet,  is  covered  up  by  the  subsequent  comj)resses,  which  are  snugly 
bandaged  to  the  trunk.  Over  the  outer  bandage  another  apron  of  rubber 
tissue  is  pinned,  the  rubber  tube  projecting  from  a  slit  in  its  middle.  ■  The 
object  of  this  is  to  j^rotect  the  bandage  from  soiling  by  regurgitant  food. 

Feeding  is  to  be  done  at  first  in  short  intervals  ;  later  on,  larger  quan- 
tities of  food  can  be  introduced  m  four  daily  doses. 

d.  Colotomy. — Eectal  obstruction,  most  commonly  by  syphilis  or  cancer, 
is  an  accepted  indication  for  the  establishment  of  an  artificial  anus,  either  in 
the  groin  or  in  the  loin.  Lumbar  and  inguinal  colotomy  each  has  special 
advantages  and  drawbacks,  the  consideration  of  which  must  determine  the 
choice  of  the  method  preferable  in  a  given  case.  While  lumbar  section  is 
extra-peritoneal,  nevertheless  injury  to  the  peritonaeum  is  very  apt  to  occur; 
finding  of  the  colon  is  not  easy  ;  sometimes  it  is  imjoossible  without  opening 
the  peritoneum,  notably  when  there  is  a  well-developed  mesocolon.  The 
shape  of  the  artificial  anus  after  the  lumbar  operation  is  mostly  excellent  on 
account  of  the  ample  mass  of  tissues  traversed  by  the  fistula ;  but  the  situa- 
tion of  the  aperture  is  unhandy,  the  patients  generally  requiring  the  aid  of 
a  second  person  for  cleaning  and  dressing  the  artificial  anus. 

Inguinal  colotomy  is  a  short  and  easy  operation,  and  provides  for  an 
openmg  located  accessibly  for  the  manipulations  of  the  patient  in  cleaning 
and  dressing  the  aperture.  Its  drawbacks  are  the  necessity  of  incising  the 
peritonaeum — a  circumstance  which  has  lost  most  of  its  terrors  since  the  in- 
troduction of  the  aseptic  method — and  the  tendency  to  troublesome  prolapse 
of  the  intestinal  mucous  membrane.  The  latter  difficulty  can  be  overcome 
by  a  discreet  proportioning  of  the  external  and  intestinal  openings. 

{a)  Lumhar  colotomy. — Finding  of  the  posterior  aspect  of  the  colon  is 
very  much  facilitated  by  insufflation  of  the  thick  gut.  This  can  be  done 
either  by  a  bellows  attached  to  a  soft  catheter  passed  in  beyond  the  stricture, 
or  by  the  similar  employment  of  a  siphon  bottle  filled  with  mineral  water 
charged  with  carbonic  acid.  The  mouth  of  the  siphon  is  connected  with 
the  catheter  by  a  piece  of  rubber  tubing,  then  the  siiDhon  is  inverted  and 
the  valve  is  opened.     The  carbonic-acid  gas,  collecting  about  the  end  of  the 


148  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

glass  tube  reaching  to  the  bottom  of  the  bottle,  escapes  into  the  gut,  and  pro- 
duces a  visible  bulging  of  the  colon. 

When  the  stricture  is  impassable  and  inflation  not  practicable,  recogni- 
tion of  the  colon  may  offer  great  difficulty.  The  landmarks  are  the  kidney 
above,  and  the  reflexion  of  the  peritonaeum  externally,  but  occasionally  they 
are  of  little  practical  use. 

Case  I. — Mrs.  C.  O.,  aged  fifty-six.  Very  extensive  far-gone  cancer  of  the  rectum 
with  involvement  of  the  uterus.  The  sti-icture  was  very  long  and  impassable.  June  25^ 
1882. — Lumbar  colotoray  was  attempted.  Though  the  kidney  and  the  reflexion  of  the 
peritonaeum  were  clearly  discerned,  the  incision  opened  the  peritonaeum,  and  the  pro- 
truding gut  turned  out  to  be  small  intestine.  The  poor  condition  of  the  patient  made 
further  prolongation  of  anaesthesia  undesirable,  therefore  the  gut  was  attached  to  the 
skin  and  incised.  The  wound  healed  promptly,  giviug  much  relief,  but  the  patient 
died  four  weeks  after  the  operation  from  emaciation,  due  in  part  to  insufficient  nutri- 
tion caused  by  the  high  position  of  the  intestinal  aperture.  Post-mortem  examination 
showed  that  the  intestinal  fistula  was  midway  between  the  stomach  and  csecum. 

Case  II. — Mrs.  Mary  Brunner,  aged  forty-three.  August  23,  1885. — Lumbar  coloto- 
my  at  Mount  Sinai  Hospital  under  ether.  August  2Jf.th,  25th. — Acute  lobar  pneumonia 
of  the  entire  right  lung,  to  which  the  patient  succumbed.  The  colotomy  wound  had 
closed  by  primary  adhesion.  Presumably  the  pneumonia  was  caused  by  the  entrance 
of  foul  oral  secretions  into  the  right  bronchus  during  tlie  operation. 

[h)  Inguinal  colotomy. — A  vertical  incision  is  preferable  to  one  parallel 
with  Poupart's  ligament.  With  the  former,  the  fibers  of  the  oblique 
muscles  will  be  cut  across  their  course  and  will  retract,  giving  ample  space 
for  a  clear  insight  and  free  manipulation.  Asepticisni  has  to  be  maintained 
as  in  all  abdominal  operations  mainly  by  scrupulous  cleanliness. 

The  peritongeum  is  sufficiently  incised  to  grasp  the  presenting  colon  with 
the  fingers  for  withdrawal,  and  its  edges  are  secured  with  four  artery -forceps. 
The  gut  will  be  known  by  its  taeniae  and  the  epiploic  appendices.     A  loop 
about  two  inches  in  length  is  withdrawn,  and  its  mesial  and  distal  halves  are 
stitched  to  each  other  in  front  and  in  the  rear  so  as  to  cause  the  formation 
of  a  spur  (a  b,  Fig.  120).     The  sutures  are  made  with  an  ordinary  straight 
sewing-needle,  the  suturing  material  being  catgut  No.  3. 
The  stitches  should  include  only  the  peritoneal  covering 
of  the  intestine.     The  loop  is  then  dropped  back  into  the 
peritoneal  incision,  and  its  apex  is  stitched  to  the  parietal 
peritonaeum  all  round  with  two  tiers  of  catgut  sutures. 
In  doing  this  the  parietal  peritonaeum  can  be  well  everted 
/  ^  \      \        by  the  artery-forceps  attached  to  it,  and  a  broad  surface 
Fio.  120.  —  Fonna-      of  contact  between  it  and  the  gut  can  be  thus  secured. 
^^^xvl^'^^lxomy'      J^inally,  the  gut  is  incised  and  the  intestinal  mucous  mem- 
brane is  sewed  to  the  outer  skin.     To  prevent  prolapse  of 
the  mucous  membrane,  or  leakage,  the  incision  should  not  be  made  too 
large.     The  formation  of  the  spur  as  suggested  by  Verneuil  has  this  advan- 
tage, that  fecal  matter  will  not  find  its  way  into  the  lowest  part  of  the 
rectum  situated  below  the  artificial  anus,  and  thus  painful  and  otherwise 
disagreeable  regurgitation  of  faeces  will  be  avoided.    At  the  same  time,  secre- 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD.         149 

tions  forming  in  the  distal  section  of  the  rectum  will  not  be  retained,  but 
can  escape  through  the  fistula. 

The  proposition  of  completely  dividing  the  loop  of  extracted  colon,  sew- 
ing the  upper  end  into  the  wound,  and  closing  by  suture  and  dropping  back 
the  distal  end,  is  feasible,  but  is  met  by  a  serious  objection.  The  stricture 
may  lead  to  complete  occlusion,  and  the  secretions  of  an  ulcerated  cancer 
may  so  distend  the  closed  gut  as  to  lead  to  rupture  of  the  sutured  part  and 
to  fatal  peritonitis. 

Case  I. — Mary  Steiger,  aged  fifty-nine.  Extensive  rectal  cancer  with  a  number  of 
periproctitic  abscesses  causing  profuse  purulent  discharge  through  the  anus.  Emaciat- 
ing hectic  fever  and  distressing  fecal  retention.  August  13,  1885. — Inguinal  colotomy 
at  the  German  Hospital.  The  thick  gut  was  witlidrawn,  and  was  closed  with  two 
ligatures  of  stout  silk  carried  through  the  mesocolon  by  the  point  of  a  thumb-forceps. 
The  peritoneal  incision  was  covered  with  two  flat  sponges  and  the  gut  was  cut  through 
between  the  ligatures.  A  little  fecal  matter  escaped  and  was  caught  by  the  sponges, 
whereupon  they  were  changed.  The  open  lumen  of  the  gut  was  mopped  out  cleanly, 
and  well  irrigated  with  Thiersch's  solution.  After  this  the  distal  end  of  the  gut  was 
closed  by  two  tiers  of  Lembert  sutures  made  with  catgut,  and  was  returned  to"  the 
abdominal  cavity.  The  peritoneal  layer  of  the  mesial  end  was  stitched  to  the  parietal 
peritonteum  and  the  mucous  membrane  to  the  outer  skin.  The  patient  rallied  well 
from  the  operation,  but  the  high  fever  and  profuse  discharge  from  the  anus  continued. 
August  18th. — Tte  patient  died  under  septic  symptoms.  On  autopsy,  the  wound  was 
found  healed  by  the  first  intention,  likewise  the  sutured  distal  end  of  the  gut.  The 
])eriton8eum  was  normal,  but  a  very  large  retro-peritonael  abscess,  communicating  with 
the  rectal  pouch  above  tlie  cancer,  extended  high  up  along  the  front  of  the  sacrum,  and 
contained  a  large  quantity  of  extremely  fetid  pus. 

Case  II. — John  Barnett,  clerk,  aged  fifty.  Inoperable  cancer  of  lower  end  of 
rectum.  November  15, 1886. — Inguinal  colotomy  with  formation  of  spur  at  Mount  Sinai 
Hospital.  November  22d. — Stitches  that  were  not  absorbed,  removed.  Funnel-shaped 
artificial  anus,  no  prolapse  of  gut.  August  10,  1887. — Wears,  with  comfort,  a  r.mall 
hollow  rubber  ball  over  the  fistula. 

Case  III. — Stephen  Y.,  government  official,  aged  sixty-one.  Far-gone  rectal  cancer, 
with  involvement  of  the  prostate  and  old  strictures  of  the  pendulous  part  of  the 
urethra.  Noteinber  15,  1886. — Inguinal  colotomy  with  formation  of  spur  at  Mount 
Sinai  Hospital  under  ether.  November  16th. — Lobular  pneumonia,  probably  caused  by 
aspiration  of  mucus  during  the  anaesthesia.  By  November  25th,  the  acute  febrile 
symptoms  had  subsided,  but  profuse  purulent  sputa  were  continually  expectorated. 
The  bladder  also  caused  much  trouble,  although  the  tight  strictures  had  been  well 
dilated.  The  urine  contained  much  pus,  later  on  blood,  coming  from  the  ulcerated 
portion  of  the  cancer  occupying  the  neck  of  the  bladder.  The  colotomy  wound  healed 
kindly,  and  a  satisfactory  artificial  anus  had  been  secured.  The  chronic  bronchial 
catarrh,  fetid  cystitis,  and  later  pyelo-nephritis,  however,  hastened  the  death  t)f  the 
patient,  which  occurred  on  December  23d. 

Xn.     HYDROCELE,    VARICOCELE,    AND    CASTRATION. 

1.   Hydrops  of  the  tunica  vaginalis  of  the  testis  is  either  an  essential 
disorder  per  se,  or  is  symptomatic  of  some  acute  or  chronic  affection  of  the 
testicle.    If  it  be  produced  by  acute  epididymitis  and  orchitis,  it  is  transient ; 
21 


150  RULES   OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 

but  if  its  cause  is  tuberculosis,  or  cancer,  or  syphilis  of  the  testicle,  it 
assumes  the  character  of  a  chronic  complaint.  For  the  sake  of  a  correct 
prognosis  the  recognition  of  secondary  hydrocele  is  important,  as  it  is  im- 
probable that,  brought  on  by  these  affections  of  the  testicle,  hydrocele  can 
be  cured  by  either  tapping  and  injection  or  the  radical  operation. 

If  the  hydrocele  is  very  tense,  preliminary  tapping  is  advisable,  in  order 
to  afford  an  opportunity  for  estimating  the  condition  of  the  testicle. 
Should  this  be  found  rugged,  swollen,  and  hard,  it  is  very  doubtful  that 
measures  directed  to  the  cure  of  the  effusion  will  be  successful,  unless  the 
condition  of  the  testicle  be  improved  by  appropriate  treatment.  Gummy 
swellings  will  usually  disappear  under  antisyphilitic  medication,  and  with 
them  the  hydrocele.  Tuberculosis  and  cancer,  on  the  other  hand,  will 
require  castration. 

The  cure  of  simple  hydrocele  by  tapping  and  suhsequent  injection  \f\i]i 
tincture  of  iodine  or  pure  carbolic  acid  is  safe,  and  is  generally  followed  by 
cure.  The  only  caution  to  be  taken  is  a  proper  disinfection  of  the  trocar  or 
cannula  to  be  used,  by  either  boiling  in  carbolized  lotion  (five  per  cent),  or 
by  heating  the  instrument  in  an  alcohol-flame.  Care  must  also  be  exercised 
not  to  leave  behind  in  the  sac  too  large  a  quantity  of  the  tincture  of  iodine, 
as  there  is  on  record  a  case  of  acute  iodine-poisoning  brought  on  by  that 
circumstance. 

Volkmann^s  radical  operation  is  also  safe,  and  offers  the  best  chances 
of  a  permanent  cure  ;  but  it  necessitates  longer  confinenent  of  the  patient 
than  the  preceding  method.     The  author  has  performed  this  operation  suc- 
cessfully thirty-two  times  on  thirty-one  patients,  and  no  serious  disturbance 
was  ever  observed  during  the  course  of  healing.    In  each 
case  cure  was  complete  in  from  two  to  three  weeks,  and 
was  permanent.     Lately  the  operation  was  done  with 
the  aid  of  local  anaesthesia  by  cocaine. 

The  procedure  is  as  follows :  The  penis  and  scrotum 
are  shaved,  scrubbed  off,  and  disinfected.  A  rubber  band 
or  drainage-tube  is  tied  about  the  root  of  the  penis  and 
scrotum,  and  about  twenty  minims  of  a  five-per-cent 
solution  of  cocaine  are  injected  along  the  prospective 
line  of  incision.  The  skin  and  dartos  are  incised  for 
about  two  inches,  and  the  exposed  tunica  is  opened.  A 
^Tiiustra'tkig'^oiT  grooved  director  is  slipped  into  the  sac,  which  is  then 
mann's  operation      gij^  open,  this  incision  being  somewhat  shorter  than  the 

for  hydrocele.  ^  ^,  .  -,         ,_      •l^ 

cutaneous  one.  The  sac  is  mopped  out  with  a  sponge 
dipped  in  a  five-per-cent  solution  of  carbolic  acid.  After  this  the  tunica  is 
stitched  to  the  skin  by  a  continuous  suture  of  fine  catgut.  A  small  drain- 
age-tube is  inserted  and  secured  from  slipping  in  by  transfixion  with  a 
safety-pin.  The  constricting  rubber  band  is  removed,  and  the  scrotum  is 
held  compressed  between  two  sponges  for  a  few  minutes  to  stanch  any  pos- 
sible hgemorrhage.  A  small  strip  of  disinfected  rubber  tissue  is  laid  on  the 
wound,  which  is  enveloped,  together  with  the  entire  scrotum,  in  a  dry  dress- 


SPECIAL  APPLICATION  OF  THE  ASEPTIC   METHOD.        151 

ing,  held,  down  by  a  roller  baudage  applied  in  the  manner  described  in  the 
paragraph  on  herniotomy.     (Fig.  121.) 

The  dressings  are  changed  on  the  tenth  day  after  the  operation.  On 
the  second  day  the  movement  of  the  bowels  is  attended  to  by  enema  or  laxa- 
tive. On  changing  the  dressings  the  patient  can  be  permitted  to  get  up  and 
to  exercise  moderately.  The  wound  is  dressed  with  a  stri^D  of  iodoformed 
gauze  until  it  is  healed. 

2.  Varicocele  of  a  moderate  degree  is  best  treated  according  to  Keyes's 
plan,  which  consists  of  subcutaneous  ligature  of  the  distended  veins  with 
catgut.  The  scrotum  being  cocainized,  the  cord  is  separated  from  the  vari- 
cose veins,  and  is  held  in  the  grasp  of  the  thumb  and  index  of  the  left  hand, 
the  patient  standing  during  the  procedure.  A  straight  Peaslee's  needle, 
armed  with  a  loop  of  silk,  is  thrust  through  the  scrotum  from  in  front  until 
its  eye  appears  behind  the  scrotum.  The  left  hand  releasing  its  grasp  is 
used  for  placing  the  ends  of  a  medium-sized  thread  of  catgut  into  the  loop 
of  silk,  which  is  then  pulled  through  forward  and  out  of  the  anterior  punct- 
ure-hole, and  the  catgut  is  released  from  the  silken  loop.  Now  the  left 
hand  grasps  again  the  scrotum,  and  the  needle  is  reinserted  exactly  into  the 
anterior  puncture-hole,  and  carried  around  the  varices  externally  to  them, 
and  close  to  the  scrotal  integument  backward,  until  it  emerges  exactly  from 
the  posterior  puncture.  The  other  end  of  the  catgut  thread  is  then  taken 
up  by  the  loop  of  silk,  and  is  brought  out  through  the  anterior  aperture  by 
withdrawing  the  needle.  Both  ends  of  the  ligature  are  now  seen  emerging 
from  the  anterior  puncture-hole.  They  are  tightly  knotted,  cut  off  short, 
and  disappear  in  the  scrotum  as  soon  as  released.  A  slight  amount  of  hard 
swelling  will  appear  around  the  jolace  of  ligature  the  next  day,  but  will  not 
cause  sufficient  discomfort  to  prevent  the  j)atient  from  attending  to  his  avo- 
cation. 

The  author  has  employed  this  method  with  the  best  success  in  four 
cases. 

Extensive  varicocele  can  be  cured  only  by  free  exposure,  double  ligature, 
and  excision  of  the  dilated  veins.  Under  aseptic  precautions  this  measure 
is  free  from  danger. 

Case. — Emil  Luhning,  baker,  aged  twenty-one.  Large  varicocele  of  the  left  side, 
extending  down  to  the  middle  of  the  inner  aspect  of  tlie  thigh.  April  25^  1882. — At 
the  German  Hospital  the  scrotal  varices  were  exposed  by  incision,  and  a  large  plexus 
was  separated  and  tied  above  and  below.  The  intervening  veins  were  exsected. 
Another  incision  of  eight  inches  in  length  exposed  the  varicose  veins  extending  down 
the  thigh,  and  they  were  also  exsected  after  being  secured  by  double  ligature.  A 
rather  wide  strip  of  attenuated  skin  had  to  be  removed  along  with  the  veins,  prevent- 
ing entire  closure  of  the  femoral  wound  by  suture.  Uninterrupted  cure  of  the  scrotal 
wound  by  primary  union  of  the  femoral  one  by  granulation.  June  22d. — Patient  was 
discharged  cured. 

Four  more  somewhat  less  extensive  cases  were  treated  in  a  similar  man- 
ner, and  all  healed  by  the  first  intention. 

Care  must  be  taken  not  to  remove  all  the  veins  of  the  pampiniform 


152  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

plexus.     In  the  authors  sixth  case  necrosis  of  the  testicle  was  caused  by  too 
extensive  excision  of  the  dilated  veins. 

Case. — -Joseph  Stern,  baker,  aged  twenty-two.  Extensive  varicocele  of  the  left 
side.  March  17,  1886. — Excision  of  varices  at  the  German  Hospital.  March  27th. — 
Necrosis  of  testicle  was  noted.  A  few  of  the  stitches  had  given  way,  and  the  yellow- 
ish, discolored  testis  was  distinctly  visible.  Ajml  8th.. — The  testicle  came  away  with 
very  moderate  sero-purulent  secretion.     April  26th. — Patient  was  discharged  cured. 

3.  Castration  is  indicated  by  neoplasms,  tuberculosis,  or  syphilis  of  the 
testicle,  in  the  latter  case,  however,  only  when  the  disease  is  not  amenable 
to  systemic  treatment,  and  is  a  source  of  much  suffering. 

The  author^ s procedure  for  ca&tration  is  as  follows  :  The  patient's  geni- 
tal region  is  shaved,  scrubbed  with  soap  and  hot  water,  and  disinfected  with 
corrosive-sublimate  lotion,  or,  if  any  open  ulcer  or  fistula  be  present,  these 
are  finally  syringed  or  touched  up  with  an  eight-per-cent  solution  of  chloride 
of  zinc.  First,  the  seminal  cord  is  exposed  well  above  the  diseased  testicle, 
and,  being  separated,  is  taken  up  by  the  index  of  the  left  hand.  The  ves- 
sels composing  it  are  successively  grasped  by  separate  artery-forceps,  while 
the  vas  deferens  remains  intact.  As  soon  as  all  the  vessels  are  thus  secured, 
they  are  nipped  off  one  after  the  other  with  the  scissors  in  front  of  the 
artery-forceps,  and  are  at  once  tied.  The  vas  deferens  is  cut  through. 
Before  being  released,  the  mesial  end  of  the  severed  cord  is  somewhat  relaxed 
and  carefully  inspected,  to  see  whether  all  bleeding  be  stanched  or  not. 

By  making  the  division  of  the  cord  the  first  step  of  the  operation,  the 
subsequent  parts  of  the  procedure  are  made  decidedly  less  bloody.  Dissec- 
tion of  the  testicle  proper  is  much  easier  and  more  rapid  than  if  the  reverse 
order  is  observed,  and  the  stump  of  the  cord  serving  as  a  convenient  handle, 
contact  of  the  surgeon's  fingers  with  ulcerating  surfaces  or  fistulas  can 
altogether  be  avoided.  A  few  more  ligatures  will  be  generally  needed  along 
the  bottom  of  the  scrotum. 

A  drainage-tube  is  inserted,  extending  from  the  inguinal  ring  down  to 
the  lower  angle  of  the  cutaneous  incision,  and  then  the  wound  is  united  by 
interrupted  catgut  sutures,  the  edges  of  the  cut  being  held  pinched  up  by 
the  fingers  in  passing  the  stitches.  A  dressing  similar  to  that  used  after 
herniotomy  is  applied  and  left  on  generally  for  eight  or  ten  days.  The  tube 
is  removed  with  the  first  dressing. 

Tying  of  the  cord  in  mass  saves  a  little  time  in  operating,  but  the  stump 
generally  necroses,  and  cure  is  very  much  delayed  by  the  slow  process  of  its 
detachment. 

Castration  was  performed  by  the  author  twenty  times ;  in  fifteen  cases 
for  tuberculosis.  One  of  these  cases  died  of  croupous  pneumonia,  probably 
induced  by  ether  ansesthesia. 

Case. — Moses  II.,  merchant,  aged  sixty.  Jamiary  24,  1887. — Castration  for  tuber- 
culosis of  right  testicle  at  Mount  Sinai  Hospital  under  ether.  The  operation  did  not  pre- 
sent anything  unusual,  and  the  patient  did  well  after  it  until  two  o'clock  on  the  after- 
noon of  January  26tli,  when  suddenly  high  fever  with  dyspnoea  appeared,  and  developed 
into  coma  within  a  few  hours.     Al    0  v.  m.  the  thermometer  indicated  106-7°  Fahr.  in 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD.         153 

the  rectum ;  at  9'55  p.  m.  the  patient  died.  Dullness  at  the  base  of  the  right  lung, 
made  out  a  few  hours  before  death,  corresponded  to  an  area  of  fresh  lobar  pneumonia 
found  at  the  autopsy.     The  wound,  peritoneal  cavity,  and  kidneys  were  normal. 

Fourteen  eases  castrated  for  tuberculosis  all  recovered. 

In  one  case  castration  was  done  for  syphilitic  gumma  of  the  left  testicle 
of  five  years'  standing,  which  had  remained  uninfluenced  by  various  kinds 
of  constitutional  treatment. 

Case. — John  W.  G.,  brewer,  aged  thirty-eiglit.  Large  hydrocele  caused  by  chronic 
specific  disease  of  the  testicle.  March  J^^  1887. — The  hydrocele  was  incised,  and  the 
testicle  was  found  very  much  enlarged ;  the  rugged  and  hard  epididymis  was  occupied 
by  a  solid  fibrous  mass  extending  weU  into  the  glandular  tissue  of  the  testicle.  Cas- 
tration was  at  once  done.  March  15th. — Patient  discharged  nearly  cured,  the  place  of 
exit  for  the  drainage-tube  presenting  a  small  spot  of  granulations. 

In  two  cases  ablation  of  the  testicle  had  to  be  done  for  malignant  neo- 
plasm.    They  recovered. 

Case  I. — Jacob  Praeger,  tailor,  aged  seventy-two.  Very  large  giant-cell  sarcoma 
of  right  testis.  Deceniber  4,  1879. — Castration.  Preparation  of  the  bowels  by  laxatives 
was  insuflicient,  and  on  the  third  day  after  the  operation  violent  colic  developed,  which 
could  not  be  controlled  by  opiates.  In  the  night  a  large  stool  escaped  into  tlie  bed, 
the  dressings  and  the  wound  were  soiled,  and  in  a  few  hours  fever  set  in.  The  wound 
was  injected  wifh  an  eight-per-cent  solution  of  chloride  of  zinc,  which  checked  the 
fever.  Much  sloughing  tissue  came  away,  but  patient  recovered,  and  was  discharged 
cured  about  five  weeks  after  the  operation. 

The  author's  experience  in  this  case  taught  him  the  valuable  lesson  of 
never  trusting  the  patients'  statement  regarding  the  action  of  their  howels, 
and  never  leaving  the  manner  of  preparation  of  the  intestine  to  their  judg- 
ment. In  this  case  the  patient  assured  the  author  that  citrate  of  magnesia 
acted  on  him  like  a  charm.  Citrate  of  magnesia  was  taken,  with  the  result 
reported  above.  Had  a  good  dose  of  oil  or  calomel  raked  out  the  flaccid 
and  coprostatic  gut  of  the  old  man  before  the  operation,  his  life  would  not 
have  been  endangered  by  subsequent  fecal  infection  of  the  wound. 

Case  II. — Siegmund  Hertz,  clerk,  aged  thirty-two.  August  24,  i555.— Castration 
of  right  testicle  for  myxosarcoma  at  Mount  Sinai  Hospital.  Primary  union.  Septem- 
ber 15th. — Patient  discharged  cured. 

Tioice  castration  teas  done  for  spontaneous  gangrene  of  the  testicle. 
Both  cases  recovered.  The  record  of  one  was  lost ;  that  of  the  other  is  as 
follows  : 

Case. — George  Otto,  butcher,  aged  thirty-nine,  admitted,  February  2,  1880,  to 
German  Hospital  with  an  enormous  emphysematous  swelling  of  the  left  testicle.  The 
organ  had  nearly  the  size  of  a  man's  head,  was  dusky  red  and  hot,  showed  crepitus, 
and  gave  tympanitic  percussion-sound.  The  patient,  a  powerfully  built  man,  showed 
symptoms  of  most  acute  septic  intoxication.  He  stated,  on  being  shaken  out  of  his 
stupor,  that  the  swelling  had  come  on  three  days  ago  suddenly  with  much  pain  after 
a  probatory  puncture.  Immediate  ablation  of  the  organ  was  done.  The  skin  was  pre- 
served, and  the  very  large  wound  cavity  was  filled  with  a  packing  of  carbolized  gauze. 
An  almost  immediate  improvement  of  the  patient's  general  condition  followed.     The 


151 


RULES  OF  ASEPTIC  AND   ANTISEPTIC  SURGERY. 


wound  healed  rather  rapidly  hy  granulation.  February  26tTi. — Patient  was  discharged 
oured.  Examination  of  the  specimen  showed  bloody  infarction  of  the  testis  and  epi- 
didymis, with  far-gone  disintegration  and  softening  of  the  tissues.  The  tunica  and 
subcutaneous  connective  tissue  were  in  a  state  of  emphysematous  gangrene. 


Xin.     ASEPTIC    OPERATIONS    ON    THE    RECTUM. 

1.  General  Observations. — The  aseptic  performance  of  rectal  operations 
done  for  hemorrhoidal  or  other  tumors  requires  a  careful  preparation  of 
the  gut.     It  consists,  first,  of  the 
administration    of  a  cathartic  like 


castor-oil  or  calomel  several  days, 
in   elderly   subjects  a 
week    before   the   op- 
eration,   followed    up 
by   the    daily   exhibi- 
tion of  a  saline  laxa- 
tive, to  be  given  on  an 
empty  stomach.    Four 
hours  before  the  time  of  the 
operation  a  large  enema  of 
soap-water    is    administered, 
and,  as  soon  as  it  has  acted. 


Fig.  122. — Lateral  view  of  patient  in  Bozeman's  position. 


a  full  dose  of  opium  is  given  by  mouth,  or  is  introduced  into  the  rectum 

in  the  shape  of  a  suppository. 

When  the  anaesthetized  patient  is  laid  on  the  operating-table,  a  good- 
sized  sponge  attached  to  a  stout  silken  thread  is 
thrust  well  up  the  rectum,  and,  the  sphincter 
bting  thoroughly  stretched  by  manual  force,  the 
anus  and  rectal  pouch  are  flushed  with  a  stream 
of  corrosive-sublimate  lotion  (1  :  1,000)  thrown 
from  an  irrigator. 
£*  "-.  ^*'^'^B|  During  the  progress  of  the  operation  irrigation 

stantly  at  short  inter- 
vals. When  the  perito- 
na3um  is  approached, 
or  has  to  be  invaded  by 
the  surgeon, Thiersch's 
solution  is  substituted 
for  the  mercuric  lotion 
as  an  irrigating  fluid.. 
2.  Haemorrhoids.— 
A  varicose  condition 
of  the  hgemorrhoidal 
veins  of  recent  origin, 
caused   by  some  dis- 


FiG.  123. — Posterior  view  of  [latient  in  Bozeman's  position. 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.         155 

turbance  of  the  i)ortiil  circulation,  in  often  amenable  to  general  treatment 
by  fulfilling  the  causal  indication.  Eemoving  a  fecal  retention,  or  regu- 
lating the  portal  circulation  with  a  dose  of  calomel,  followed  up  by  a  course 
of  Carlsbad  salts,  will  often  do  away  with  the  hgemorrhoids  caused  by  these 
conditions.  Or  regulation  of  the  heart's  action  by  digitalis  in  valvular 
lesions  will  be  followed  by  marked  improvement.  When  the  haemorrhoidal 
nodes  are  in  a  state  of  acute  phlebitis,  marked  by  painful  hot  swelling  and 
fever,  topical  applications  of  cold  in  the  shape  of  enemata  of  ice-water  or 
iced  compresses  will  give  much  relief. 

Aggravated  cases,  however,  especially  when  there  is  a  state  of  prolaj^se 
of  the  mucous  membrane  of  the  anus,  can  be  cured  only  by  operative  meas- 
ures. 

Of  all  operations  for  the  cure  of  haemorrhoids,  that  by  ligature  com- 
mends itself  as  the  simplest  and  safest.  This  statement  is  based  on  an 
experience  gathered  from  several  hundred  cases  operated  by  the  author 
according  to  various  methods. 

The  manner  of  procedure  is  as  follows  :  The  ansesthetized  patient  is 
brought  either  in  the  lithotomy  position,  with  a  hard  cushion  under  his 
buttocks,  or  he  is  arranged  in  Bozeman's  manner  for  the  operation  of  vesico- 
vaginal fistula  (Figs.  122  and  123).  This  latter  position  is  especially  use- 
ful where  the*  assistance  needed  for  holding  the  patient  in  the  lithotomy 
position  can  not  be  procured.  In  both  cases  the  feet  and  legs  of  the  patient 
should  be  protected  from  exposure  by  a  wrapping  of  rubber  sheets.  These 
should  be  covered  over  with  clean  towels  wrung  out  of  mercuric  lotion  for 
the  protection  of  the  assistants'  hands  from  contamination. 

Selecting  the  lithotomy  position,  the  patient's  palms  should  be  brought 
in  contact  with  his  soles,  and  this  relation  should  be  secured  by  tight  band- 
aging. The  operator,  well  protected  by  a  rubber  apron,  takes  a  seat  in  front 
of  the  patient,  and  proceeds  to  vigorously  stretch  the  sphincter  ani  muscle 
with  his  thumbs  inserted  in  the  anus.  As  soon  as  the  sphincter  is  paralyzed 
by  stretching,  the  hgemorrhoidal  nodes,  external  and  internal,  will  spontane- 
ously protrude.  A  sponge  secured  with  a  thread  of  silk  is  thrust  into  the 
rectum,  and  the  field  of  operation  is  cleansed  by  irrigation.  The  lowest 
node  is  grasped  with  an  artery  forceps,  and,  being  well  drawn  out,  is  cir- 
cumscribed by  a  shallow  incision  made  with  a  pair  of  curved  scissors.  A 
curved  needle  is  taken,  armed  with  a  double  thread  of  stout  disinfected  silk, 
and  with  it  the  base  of  the  tumor  is  transfixed  from  without  inward.  The 
silk  is  cut  near  the  needle,  and,  the  threads  being  separated,  the  base  of  the 
node  is  tied  in  two  portions.  The  node  is  cut  off  below  the  ligatures,  and 
then  the  remaining  nodes  are  attended  to  in  a  similar  manner.  When  the 
operation  is  finished,  some  iodoform  powder  is  rubbed  into  the  nodal  stumps, 
and,  after  a  final  irrigation,  the  sponge  is  withdrawn  from  the  rectum, 
which  is  mopped  out  dry  with  another  sponge  attached  to  a  long  stick  or 
sponge-holder.     (Fig.  124,  a  and  c.) 

A  hollow  tampon  is  next  prepared  by  wrapping  a  few  layers  of  iodoform- 
ized  gauze  around  a  piece  of  stout  rubber  tubing  three  inches  long.     This 


156 


RULES   OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 


is  introduced  into  the  rectum  well  beyond  the  sphincter,  and  its  protruding 
end  is  transfixed  with  a  large-sized  safety-pin.     (Fig.  125.) 

The  object  of  this  tampon  is  twofold.     Its  main  object  is  to  facilitate 

the  escape  of  flatus,  a  circumstance  highly 
appreciated  by  elderly  flatulent  individuals. 
Another  purpose  is  the  prevention  of  oozing 
from  the  stitch-holes. 

The  anal  region  is  thickly  anointed  with 
vaseline,  and,  the 
safety-pin  being  un- 
der-padded with  a 
few  strips  of  iodo- 
formized  gauze,  a 
large  pad  of  corros- 
ive-sublimate gauze 
is  held  down  to  the 
anus  by  a  T-band- 
age.     (Fig.  136.) 

Forty-eight  hours 
after  the  operation 
four  ounces  of  sweet 
oil   are    injected    into 
the    rectum    through 
the  rubber  tube,  which 
can    be   withdrawn    a 
short  while  after  with 
very  little  pain  to  the 
patient.     A  large  ene- 
ma of  soap- water  is  at 
once  administered,  and 
generally  is  followed  by  an  evacuation  of  the 
bowels.    After  the  stool  another  small  enema 
is  given  to  cleanse  the  hsemorrhoidal  stumps 
of  adherent  faeces.     The  anus  is  dressed  with 
a  strip  of  iodoformized  gauze  and  a  pad  as 
before. 

The  next  morning  a  dose  of  salts  is  given,  and,  stool  following,  the  rec- 
tum is  again  washed  out  afterward.  This  practice  may  have  to  be  repeated 
once  or  twice  within  the  next  few  days. 

The  patient  may  be  permitted  to  get  up  about  ten  days  after  the 
operation,  but  must  remain  at  home  till  after  the  detachment  of  the 
ligatures. 

Cauterization  with  fuming  nitric  acid  was  formerly  also  much  employed 
by  the  author  ;  but  in  one  case  almost  fatal  hgemorrhage  occurred  from  a 
small  artery  just  within  the  sphincter  on  the  detachment  of  the  eschar. 
Since  then  the  author  has  abandoned  this  practice. 


SPECIAL  APPLICATION   OF  THE  ASEPTIC   METHOD. 


157 


Fig.  125. — Tampon-tube. 


Case. — Mr.  M.  P.,  gilder,  nged  thirty-one.  Febru- 
ary 24,  i55^.— Cauterization  of  external  and  internal 
liaBraorrboids  with  nitric  acid.  March  10th. — At  2  a.  m. 
the  author  was  hastily  summoned  to  the  bed-side  of 
the  patient,  and  found  him  in  a  collapsed  condition. 
He  reported  that  shortly  after  supper  he  felt  a  desire 
to  stool,  and  had  a  copious  evacuation.  Evacuations 
followed  since  then  about  every  hour,  but,  the  closet 
being  dark,  he  could  not  say  whether  the  stools  were 
bloody.  At  1  a.  m.,  on  coming  back  to  bed  from  the 
water-closet,  the  patient  fainted.  Being  brought  to 
bed,  another  stool  followed,  consisting  of  a  large  clot 
and  some  liquid  blood.  The  patient  was  at  once  anaes- 
thetized, and,  a  speculum  being  inserted,  a  rather  large- 
sized  artery  was  seen  spurting  from  where  an  eschar 
had  been  detached  just  inside  of  the  sphincter.  The 
vessel  was  seized  and  tied,  and  the  patient  made  a  good 
recovery. 

Langeiiheclc's  clamp  and  actual  cautery  meth- 
od is  very  good  and  safe,  its  only  drawback  be- 
ing the  necessity  for  a  cautery  apparatus.  Care 
must  be  taken  not  to  grasp  with  the  clamp  the 
nodes  too  near  their  base,  as  the  resulting  eschar  is  apt  to  be  very  large, 
and  anal  stricture  may  follow.     The  hollow  tampon  is  very  useful  in  this 

method  also,  and  its 
use  can  be  warmly 
recommended  (Fig. 
124,  b). 

3.  Rectal  Tu- 
mors. —  Since  the 
publication  of  Volk- 
mann's  remarkable 
results  achieved  by 
extirpation  of  the 
rectum  for  cancer, 
the  operation,  for- 
merly condemned, 
has  met  with  fre- 
quent imitation. 
The  author's  mel- 
ancholy record  of 
six  deaths  out  of 
eight  operations  has 
nothing  to  inspire  great  confidence.  It  must  be  said,  however,  that  most 
of  these  operations  were  performed  under  very  unfavorable  conditions.  All 
the  patients  presented  instances  of  very  extensive  involvement  of  the  gut, 
requiring  in  each  case  the  removal  of  more  than  three  inches — in  one  case, 
22 


Fig.  126. — T-bandaffe  in  ,iiti/. 


158  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

nine  inches — of  intestine.  Almost  all  of  them  were  performed  during  the 
first  years  of  the  author's  independent  surgical  activity,  when  his  mastery 
of  the  difficult  technique,  both  of  the  aseptics  and  hemostasis  of  the  region 
in  question,  was  imperfect.  Much  unnecessary  haemorrhage  was  incurred, 
and  several  of  the  most  important  cautelae  against  infection  remained  unem- 
ployed. Accordingly,  two  patients  died  shortly  after  the  operation  of  col- 
lapse, due  to  acute  anaemia;  two  died  of  purulent  peritonitis,  caused  by 
infection  of  the  incised  peritonaeum  ;  one  died  of  septicaemia,  induced  by 
the  presence  of  a  large  retroperitoneal  abscess,  extending  far  up  in  front  of 
the  vertebral  column.  One  patient,  a  very  fat,  flabby  woman,  died  of  lobar 
pneumonia  at  a  time  when  the  wound  was  nearly  healed. 

Two  cases  of  very  extensive  removal  of  the  rectum  made  a  remarkably 
short  and  easy  recovery. 

Case  I. — Ed.  Turner,  mechanic,  aged  twenty -nine.  Extensive  soft  adenoid  cancer 
of  the  rectum,  of  rapid  growth.  The  involved  part  of  the  gut  was  freely  movable, 
although  its  upper  limit  could  not  be  reached  by  the  tip  of  tlie  index-finger.  Novem- 
'ber  ir*?,  ISSJf. — Extirpation  of  the  rectum  at  Mount  Sinai  Hospital.  As  the  growth 
did  not  extend  downward  to  within  an  inch  of  the  sphincter,  this  muscle  was  pre- 
served. The  coccyx  was  exposed  by  a  posterior  median  incision,  and  was  exsected. 
The  mucous  membrane  of  the  lower  end  of  the  gut  was  dissected  up  in  the  shape  of  a 
cylinder,  and  was  closed  by  a  ligature  to  prevent  the  escape  of  rectal  contents  during 
tlie  operation.  Every  vessel  was  immediately  secured  and  tied,  either  at  being  cut  or 
before  division,  if  it  could  be  previously  recognized.  The  levator  ani  muscle  was 
detached  by  dissection  from  the  intestine.  All  resisting  bands  of  tissue,  mostly  con- 
taining vessels,  were  secured  by  double  mass  ligatures  before  being  divided.  Most  diffi- 
culty was  met  with  in  freeing  the  gut  from  its  attachments  to  the  deep  pelvic  fascia, 
but  by  dint  of  mass  ligatures  this  was  also  overcome.  As  soon  as  the  pelvic  fascia  was 
passed,  the  intestine  readily  yielded  to  traction,  and  was  witlidi'awn  until  the  upper 
limit  of  the  tumor  was  distinctly  felt  through  the  walls  of  the  gut.  The  peritoneeum 
was  detached  anteriorly  by  blunt  separation,  but  it  had  to  be  incised  on  the  posterior 
aspect  of  the  rectum  to  permit  complete  removal  of  the  growth.  The  gut  was  grasped 
with  a  large  clamp-forceps  about  an  inch  above  the  tumor,  and  was  severed.  The 
patent  orifice  of  the  rectum  was  carefully  cleansed  and  disinfected,  and,  the  clamp 
being  removed,  a  number  of  vessels  of  the  rectal  wall  were  secured  and  tied.  During 
the  whole  operation  the  wound  was  almost  constantly  irrigated  with  corrosive-subli- 
mate lotion  (1  :  2,500).  The  peritoneal  incision  being  closed  by  catgut  suture,  the 
wound  was  loosely  packed  with  iodoformized  gauze  after  the  insertion  of  two  drain- 
age-tubes into  its  bottom,  and  the  gut  was  attached  to  the  skin  by  two  silk  sutures. 
The  ends  of  the  drainage-tubes  were  left  projecting  from  the  dressings,  and  the  wound 
was  flushed  through  them  at  regular  intervals  of  an  hour.  The  temperature  remained 
normal  except  on  the  sixth  day,  when  it  rose  to  103°  Fahr.  The  patient  complained 
of  colicky  pains,  and  a  saline  purge  was  administered.  A  stool  following,  the  fever 
disappeared.  The  wound  was  carefully  cleansed  by  irrigation  after  each  stool,  and 
liealed  in  spite  of  its  great  extent  in  six  weeks.  The  removed  portion  of  the  gut  meas- 
ured, when  laid  upon  the  table,  just  five  inches. 

The  resulting  incontinence  of  the  widely  patent  gut  was  remedied  by  a  procto- 
plasty performed  February  28,  1885,  at  the  German  Hospital.  The  divided  ends  of 
the  preserved  sphincter  muscle  were  dissected  (jut,  and  were  united  by  a  row  of  catgut 
stitches  placed  in  the  median  line.     In  Ajjril,  1887,  the  patient  was  free  from  relapse. 


SPECIAL  APPLICATION   OF  THE   ASEPTIC   METHOD.        159 

Case  II. — Eugene  Ilaffner,  waiter,  aged  twenty-four.  Relapsing  cancer  of  rectum 
after  extiri)ation  done  by  Dr.  F.  Lange.  February  2J^^  1887. — Extirpation  of  addi- 
tional two  inches  of  the  gut  at  the  German  Hospital.  Peritona3um  was  found  descended 
to  within  half  an  inch  from  the  skin.  It  liad  to  be  freely  incised,  and  was  subsequently 
closed  by  five  catgut  sutures.  Uninterrupted  recovery.  April  2d. — Patient  was  dis- 
charged cured. 

Tlie  niaiu  source  of  infection  is  the  interior  of  the  gnt.  To  exclude  this 
danger,  the  lower  end  of  tlie  rectum  must  be  closed  by  a  circular  ligature. 
When  the  gut  is  divided  above,  care  must  be  taken  to  prevent  soiling  of 
the  wound  by  escaping  intestinal  contents. 

XIV.    ASEPTICS    OF    THE    BLADDER. 

1.  Catheterism, — Infectious  processes  rarely  originate  in  the  bladder 
itself.  Their  most  common  way  of  entrance  is  by  the  urethra  from  with- 
out ;  next  to  this  come  the  modes  of  infection  from  within — that  is,  by 
descent  from  the  kidneys  or  by  extension  of  contiguous  septic  processes 
from  the  organs  located  in  the  vicinity  of  the  bladder,  as  for  instance  from 
peritoneal  or  retro-peritoneal  suppurations. 

As  before  indicated,  the  most  common  source  of  infection  of  the  bladder 
is  an  unclean  catheter.  The  ordinary  metliods  of  cleansing  metallic  catheters 
by  flushing  with  hot  or  cold  water,  and  subsequent  rubbing  off  ivith  a  clean 
towel,  are  altogether  inadequate.  In  order  to  secure  their  absolute  cleanli- 
ness, the  same  processes  of  sterilization  must  be  employed  that  were  recom- 
mended for  cleansing  other  hollow  tubes — notably,  aspirating  needles  and 
trocars.  Boiling  for  an  hour  in  water,  or  passing  the  instrument  through 
an  alcohol  flame  until  all  organic  matter  contained  in  its  lumen  is  volatilized 
by  burning,  is  meant  thereby.  Only  after  smoke  and  steam  have  ceased  to 
escape  from  the  catheter  can  it  be  declared  to  be  surgically  clean. 

Before  use,  the  cleansed  catheter  should  be  placed  in  a  tray  or  flat  pan 
filled  with  tepid  salt  water  (6  : 1,000,  or  one  heaped  teaspoonful  to  a  quart 
of  boiled  water) ;  the  surgeon's  hands  should  be  previously  well  washed  with 
soap  and  hot  water,  and  the  instrument  should  be  anointed  with  iodoform- 
ized  vaseline  of  the  strength  of  1 :  50  (fifteen  grains  to  two  ounces). 

Note. — The  ordinary  solutions  of  corrosive  sublimate  or  cai-bolic  acid  corrode  the  mucous 
membrane  of  the  urethra  and  bladder,  often  causing  intense  pain  and  reflex  symptoms.  The 
resulting  denudations  of  the  epithelial  layer  all  may  serve  as  portals  of  subsequent  infection, 
manifesting  itself  in  the  form  of  urethral  fever,  urethritis,  cystitis,  and,  in  extreme  cases, 
metastatic  processes.  None  of  these  very  active  germicides  should  be  introduced  into  the 
healthy  urethra  or  bladder :  first,  because  they  are  unnecessary ;  and,  secondly,  because  they 
may  do  harm.  Simple  immersion  of  a  filthy  catheter  into  these  germicidal  lotions  will  not  dis. 
infect  it  sufficiently,  and,  if  some  of  the  strong  solution  be  carried  into  the  urinary  passages 
along  with  a  filthy  catheter,  the  chances  of  infection  will  only  be  increased  by  the  combination. 
Catheters  that  were  immersed  in  strong  disinfectant  solutions  should  be  freed  from  them  before 
being  used. 

In  passing  the  instrument  into  the  bladder  for  exploration  or  evacuation, 
the  utmost  gentleness  should  be  exercised,  not  only  for  the  sake  of  the 


100  RULES   OF  ASEPTIC   AND   ANTISEPTIC   SURGERY. 

patient's  comfort,  but  also  because  it  is  of  importance  not  to  injure  the 
urethral  mucous  membrane.  Certain  parts  of  the  normal  male  urethra  will 
often  raise  obstacles  to  the  passage  of  the  instruments  which  should  never 
be  overcome  by  force,  but  only  by  patient  and  gentle  manipulation. 

The  first  obstacle  is  usually  met  at  the  susi^ensory  or  triangular  ligament. 
Holding  the  shank  of  the  catheter  parallel  with  the  abdominal  wall  while 
gently  extending  the  penis  upward  in  the  same  direction,  thus  pulling  the 
latter  over  the  former  like  a  glove-finger  over  a  finger,  will  easily  guide  the 
beak  of  the  catheter  around  the  promontory  formed  by  the  inferior  margin 
of  the  symphysis  pubis. 

The  second  obstacle  will  be  occasionally  found  in  the  sinus  of  the 
bulbous  portion.  This  pitfall  must  be  avoided  by  exerting  digital  pressure 
upon  the  perinaeum,  and  indirectly  upon  the  beak  of  the  catheter  while 
gently  depressing  its  handle.  In  sensitive  urethrse,  the  compressor  urethrge, 
or  "  cut-off  "  muscle,  will  offer  by  reflex  contraction  considerable  resist- 
ance to  the  progress  of  the  operation,  especially  if  an  instrument  of  small 
caliber  be  employed.  It  is  injudicious  to  force  this  obstacle.  A  better 
plan  is  to  abide  the  moment  when  the  muscle  will  relax,  the  instrument 
being  held  against  the  resisting  band  by  gentle  pressure.  As  soon  as  relaxa- 
tion begins,  the  point  of  the  catheter  will  be  felt  slipping  through  the 
contracted  part  of  the  urethra. 

The  enlarged  prostate  is  the  last  and  most  difficult,  because  deepest, 
impediment  that  may  retard  the  operator.  A  long-beaked  instrument  will 
penetrate  to  the  bladder  easier  than  any  other  one.  The  handle  of  the 
catheter  must  be  deeply  depressed  between  the  thighs  of  the  patient,  and,  if 
this  be  insufficient,  the  tip  of  the  left  index  introduced  in  the  rectum  must 
aid  the  entrance  of  the  beak  by  gentle  upward  pressure. 

Properly  performed  catheterism  of  a  healthy  urethra  and  Madder  should 
not  he  folloiued  by  hmmorrhage. 

Soft  catheters  made  of  gum  elastic  or  webbing  impregnated  with 
resinous  matter  are  never  safe  unless  their  history  is  known  to  the  operator. 
They  should  be  new,  or,  at  least,  such  should  never  be  employed  that  had 
been  previously  used  on  a  septic  case,  or  were  not  carefully  cleansed,  disin- 
fected, and  preserved  in  a  projoer  manner  after  use. 

Soft  gum-elastic  or  Nelaton  catheters  are  very  cheap,  and  need  not  be 
preserved  after  having  been  used  in  a  septic  case.  Before  employing  a  soft 
catheter,  it  must  be  soaked  for  ten  minutes  in  hot  soap-water  and  flushed 
out  with  it ;  then  it  is  disinfected  with  a  strong  germicide  lotion,  preferably 
corrosive  sublimate,  from  which  it  must  be  freed  again  by  another  flushing 
with  salt  water  before  it  is  anointed  with  iodoformized  vaseline  for  intro- 
duction. 

After  use,  the  catheter  should  be  again  flushed  out  thoroughly  with  car- 
bolic or  mercurial  lotion,  dried,  and  put  away  in  a  tight  box  or  wide- 
mouthed  bottle.  If  needed  frequently,  the  catheter  should  be  kept  im- 
mersed in  a  two-per-cent  carbolic  lotion.  Before  use,  however,  the  adherent 
carbolic  lotion  must  be  always  removed  by  washing  in  salt  water.      The 


SPECIAL   APPLICATION   OF  THE  ASEPTIC  METHOD.         H',] 

author  saw  a  considerable  number  of  cases  in  which  catheterism  had  to  bo 
done  for  some  time  after  rectal  operations,  and  in  which  troublesome 
urethritis  developed  on  account  of  the  corrosion  caused  by  frequent  contact 
of  the  urethral  mucous  membrane  with  the  carbolic  acid  adherent  to  the 
elastic  catheter. 

Searching  a  non-dilated  bladder  for  stone,  tumors,  or  foreign  bodies 
would  lead  to  superficial  injury  of  the  mucous  membrane  ;  therefore,  dilata- 
tion, by  injecting  three  or  four  ounces  of  salt  water,  should  precede  every 
exploration.  After  completion  of  the  search,  clots  should  be  removed  by 
irrigation  with  the  saline  solution. 

These  remarks  refer  to  bladders  only  that  discharge  normal  urine. 

Whenever  examination  of  the  urine  gives  evidence  of  a  catarrhal  or 
septic  condition,  every  intravesical  manipulation  must  be  preceded  by  disin- 
fection of  the  bladder  by  Thiersch's  solution,  or  a  lotion  consisting  of  one 
part  of  permanganate  of  potash  to  five  thousand  parts  of  tepid  water.  The 
operation  should  be  completed  by  another  disinfecting  irrigation  of  the 
organ. 

2.  Litholapaxy. — The  rapid  and  complete  evacuation  of  the  bladder  in 
one  session,  of  all  fragments  produced  by  crushing  concrements  with  a 
lithotrite,  forms  a  most  valuable  improvement  of  the  technique  of  lithotripsy. 
Bigelow's  evacuator  enables  the  surgeon  to  free  the  bladder  at  once  of  all 
sharp-edged  fragments  of  stone.  This  circumstance  justifies  the  prolonga- 
tion of  the  operation  to  an  extent  formerly  considered  unsafe,  as  subse- 
quent irritation  caused  by  the  presence  of  sharp  fragments  is  thus  done 
away  with. 

Before  introducing  the  lithotrite,  strictures  ought  to  be  cut  or  divulsed, 
and  the  bladder  ought  to  be  thoroughly  washed  out  with  tepid  permanganate- 
of-potash  or  boro-salicylic  solution.  After  this  the  bladder  is  filled  with 
from  three  to  four  ounces  of  tepid  boro-salicylic  lotion,  and  the  lithotrite  is 
introduced  well  anointed  with  iodoformized.  vaseline.  The  penis  is  tightly 
deligated  with  a  piece  of  rubber  tubing,  and  the  stone,  being  grasped,  is 
crushed  first  into  a  number  of  larger,  and  subsequently  into  as  many  small 
fragments  as  possible.  The  crushing  instrument  is  removed  and  is  replaced 
by  the  evacuating  catheter,  which  is  connected  with  the  evacuating  bulb, 
that  was  previously  filled  with  boro-salicylic  lotion.  All  small  fragments 
are  next  sucked  out  of  the  bladder  by  the  apparatus.  Should  a  peculiar 
click  indicate  the  fact  that  one  or  more  fragments,  too  large  to  pass  the 
catheter,  are  still  remaining,  the  lithotrite  must  be  introduced  anew  to  com- 
plete their  reduction  to  a  proper  size,  after  which  complete  evacuation  will 
meet  no  difficulty. 

The  bladder  is  washed  out  again  until  the  irrigating  fluid  returns  free 
from  blood,  and  the  patient  is  brought  to  bed. 

Small  stones,  especially  of  the  softer  varieties,  are  eminently  suited  for 
this  treatment,  which  has  the  great  advantage  of  a  short  convalescence  ; 
hut  its  disadvantage  of  a  possible  relapse  from  failure  to  remove  all  frag- 
ments can  not  be  denied. 


162  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Case  I. — Moritz  Witzkal,  peddler,  aged  fifty.  April  5,  188J^. — Litholapasy  at  the 
German  Hospital.  Uratic  stone  with  phosphatic  shell  weighing  four  drachms  fifty- 
five  grains.  Duration  of  operation,  thirty-five  minutes.  Discharged  April  28th.  In 
June,  patient  was  readmitted  for  stone,  which  was  removed  hy  Dr.  Adler  by  median 
lithotomy. 

Case  II. — Mr.  E.  B.,  clerk,  aged  twenty-one,  renal  colic  followed  hy  symptoms  of 
stone  in  the  bladder,  which  was  diagnosticated  by  sounding.  In  March,  1887,  lithot- 
rity  and  evacuation.  The  bladder  symptoms  continued  until  June,  when  Dr.  Schede, 
of  Hamburg,  removed  another  small  calculus. 

The  author  performed  litholapaxy  in  four  more  cases. 

Case  III. — Edward  Mink,  baker,  aged  twenty-one.  January  26,  1881. — Eapid 
lithotrity  for  a  phosphatic  calculus  weighing  two  hundred  and  fifty  grains.  March 
5th. — Patient  discharged  cured. 

Case  IV. — Henry  Bowitz,  agent,  aged  forty.  ApTil  2]j.,  1881^. — Litholapaxy  for 
uratic  calculus,  weighing  three  drachms  and  ten  grains,  at  Mount  Sinai  Hospital. 
May  10th. — Patient  discharged  cured. 

Case  V. — Francis  Johnson,  druggist,  aged  forty-seven.  Phosphatic  calculus, 
ammoniacal  urine.  October  6,  1883. — Rapid  lithotrity  at  Mount  Sinai  Hospital. 
"Weight  of  stone,  forty  seven  grains.  Duration,  fifty -five  minutes.  Discharged  cured, 
October  27th. 

Case  VI. — Philip  Prinz,  shoemaker,  aged  fifty-nine.  Rapid  lithotrity  for  small 
uratic  calculus,  done  January  25,  1887,  at  German  Hospital.  On  the  day  following 
the  operation  all  the  symptoms  of  stone  disappeared,  but  the  patient  sustained  a  burn 
of  the  legs  requiring  surgical  treatment.     This  delayed  his  discharge  until  March  17th. 

Intense  forms  of  cystitis  caused  by  the  presence  of  calculi  require  after 
lithotrity  continued  treatment  of  the  bladder  by  irrigation. 

3.  Cystotomy. — In  perineal  as  well  as  in  suprapubic  cystotomy,  the  con- 
dition of  the  urine  should  serve  as  a  guide  in  determining  whether  aseptic 
or  antiseptic  measures  have  to  be  observed  during  the  operation.  When  the 
normal  condition  of  the  urine  indicates  that  the  vesical  mucous  membrane 
is  in  a  healthy  state,  strong  disinfecting  solutions  should  not  be  used  within 
the  bladder,  and  the  surgeon's  chief  attention  should  be  directed  to  the  care- 
ful cleansing  of  his  instruments,  in  order  to  avoid  the  introduction  of  filth 
into  the  bladder.  For  purposes  of  filling  and  cleansing,  a  saline  or 
Thiersch's  solution  will  be  all  sufficient. 

In  cases  characterized  by  pyuria,  with  or  without  ammoniacal  odor,  or 
with  outright  fetidity  of  the  urine,  disinfection  of  the  bladder  must  precede 
and  follow  each  operation. 

The  rules  of  asepticism  referring  to  the  treatment  of  the  external  wound 
must  also  be  scrupulously  observed.  During  the  after-treatment,  drainage 
of  the  bladder  may  be  required,  especially  in  cases  where  a  septic  condition 
of  the  organ  would  render  retention  of  fetid  urine  undesirable  or  risky.  A 
rather  stout  rubber  drainage-tube  inserted  in  the  bladder  will  answer  every 
practical  purpose. 

(rt)  Perineal  Section  : 

Case  I. — Fred.  Kurtz,  aged  fifty-five.  Phosphatic  stone,  ammoniacal  urine.  Feb- 
ruary  1,  1881. — Lateral  lithotomy  at  the  German  Hospital,     Weight  of  stone,  three 


SPECIAL  APPLICATION   OF  THE  ASEPTIC  METHOD. 


163 


drachms  and  forty  grains.     No  reaction  or  fever.    Continued  washings  of  bladder  with 
salicylic-acid  solutions.     April  10th. — Discharged  cured. 

Case  II. — Hugo  Liedtke,  aged  three  and  a  half.  Small  uratic  stone.  March  19, 
1881. — Lateral  lithotomy  with  the  assistance  of  the  family  attendant,  Dr.  Hassloch. 
Weight  of  stone,  eighteen  grains.     April  15th. — Discharged  cured. 


Fjg.  127.  — Arrangeiucnt  oi'  ptitiunt  I'or  iieriueal  cystotomy,     i'uet  wni2")iiC'd  up  in  disinfected  towels. 

(b)  SuPEAPUBic  Section. — Tumors,  a  very  large  prostate,  encysted  or 
very  large  stones,  oxalic  concrements,  or  rebellious  cystic  haemorrhage  from 
dilated  veins  of  the  neck  of  the  bladder,  indicate  the  selection  of  the  high 
operation.  Petersen  and  Garson's  proposition  to  distend  both  bladder  and 
rectum  before  cutting,  marks  a  most  valuable  improvement  of  the  method, 
as  injury  to  the  anterior  reflection  of  the  peritonaeum  can  be  thus  avoided. 
A  soft  rubber  bag,  or  "colpeurynter,"  similar  to  Barnes's  dilator,  is  intro- 
duced into  the  rectum,  and  is  filled  with  from  fifteen  to  eighteen  ounces  of 
water.  Escape  of  the  water  is  prevented  by  attaching  an  artery  forceps  to 
the  end  of  the  tube. 

Seven  or  eight  ounces  of  tepid  salt  water  or  boro-salicylic  lotion  are 
injected  into  the  bladder,  and  the  penis  is  tied  with  a  piece  of  rubber  tub- 
ing. The  patient's  shaved  suprapubic  region  is  carefully  disinfected,  and 
a  median  incision  is  made,  commencing  about  three  inches  above,  and  ex- 
tending to  the  symphysis.  The  recti  muscles  are  separated,  and  the  pre- 
vesical fat  is  incised.  Care  must  he  taken  not  to  injure  the  reflexion  of  the 
peritonceum,  which  may  he  looked  for  in  the  upper  angle  of  the  wound.  In 
many  cases  the  peritonaeum  will  not  come  in  view  at  all.  Should  distention 
of  the  rectum  and  bladder  not  suffice  to  push  up  and  out  of  the  way  the 
peritoneal  fold,  this  must  be  separated  from  the  bladder  by  blunt  dissection, 
to  be  done  preferably  by  the  tips  of  the  fingers.  Vessels  crossing  the  pre- 
vesical space  should  be  divided  between  double  ligatures. 

The  bladder  is  transfixed  on  each  side  of  the  median  line  with  curved 
needles,  carrying  fillets  of  silk.     The  vesical  incision  is  made  between  these 


164 


RULES   OF  ASEPTIC   AND   ANTISEPTIC  SURGERY. 


hold-fasts  with  a  sharp-pointed  bistoury.  In  cases  of  doubt,  the  presen ting- 
organ  may  be  first  punctured  with  a  hypodermic  needle.  While  the  silken 
threads  keep  the  vesical  wound  patulous,  the  surgeon's  finger  explores  the 
interior  of  the  bladder.  Stones  are  then  extracted  with  forceps,  or  the 
scoop,  or  even  with  the  fingers,  tumors  are  inspected  and  excised  under  the 
guidance  of  the  eye,  and  bleeding  varices  of  the  neck  of  the  bladder  are 
grasped  and  tied  off  or  touched  with  the  thermo-cautery. 

After  thorough  irrigation,  a  T-shaped  drainage-tube  (Fig.  138)  is  inserted 
in  the  bladder,  and  the  external  wound  is  loosely  packed  with  iodoformized 
gauze.  A  split  compress  of  the  same  material  is  ar- 
ranged about  the  projecting  end  of  the  tube,  and  is 
covered  with  a  number  of  compresses  consisting  of 
corrosive-sublimate  gauze.  The  skin  all  around  the 
wound  is  profusely  anointed  with  iodoformized  vase- 
line, and  the  dressings  are  held  down  by  a  few  turns 
of  a  roller-bandage.  The  patient  is  brought  to  bed, 
and  is  laid  on  his  side  upon  a  circular  air-cushion, 
his  back  being  supported  by  a  number  of  cushions 
held  up  by  the  backs  of  several  chairs,  or  by  boards 
stuck  into  the  side  of  the  bed.  As  the  lateral  posi- 
tion has  to  be  maintained  for  three  days  at  least, 
sides  should  be  changed  every  two  or  three  hours. 
The  drainage-tube  projecting  from  the  dressings  is 
connected  with  a  longer  tube,  that  is  led  into  a  urinal 
placed  alongside  the  patient  in  or  out  of  bed.  As 
soon  as  the  urine  ceases  to  be  bloody,  and  its  reaction 
becomes  acid,  the  patient  may  be  allowed  to  assume 
the  supine  posture.  The  drainage-tube  can  be  re- 
moved on  the  fifth  day,  when  the  wound  will  be  usu- 
ally found  in  a  state  of  healthy  granulation.  The  packing  of  iodoformized 
gauze  has  to  be  continued  as  long  as  urine  escapes  through  the  wound.  As 
soon  as  urination  per  vias  naturales  is  re-established,  the  wound  should  be 
dressed  as  any  other  superficial  wound. 

Case  I. — Martin  Gyr,  laborer,  aged  fifty.  Large  oxalic  calculi  of  ten  years'  stand- 
ing, with  undilatable  bladder.  Wretched  general  condition.  April  W,  iS56.— Supra- 
pubic lithotomy  at  the  German  Hospital  under  chloroform,  which  was  preferred  to 
ether  on  account  of  the  presence  of  casts  in  the  urine.  Two  immovable  stones  were 
found  occupying  the  contracted  bladder.  They  were  grasped,  freed  by  rotation,  and 
extracted  one  after  the  other.  They  showed  on  extraction  two  freshly  broken  sur- 
faces, corresponding  to  as  many  pedicle-like  projections,  branching  into  two  diverti- 
cles,  each  containing  a  separate  calculus.  One  of  these  calculi  was  extracted,  the  othei- 
and  smaller  one  was  left  behind,  as  the  patient's  poor  condition  verging  on  collapse 
did  not  justify  continuation  of  the  operation.  The  patient  did  not  rally  from  the  col- 
lapse, and  died  three  hours  after  the  completion  of  the  lithotomy. 

The  suprapubic  incision  gave  free  access  to  the  bladder,  and  enabled  the 
author  to  conduct  the  search  and  extraction  of  the  calculi  under  the  guid- 


FiG.  128.— T-shaped  drain- 
age-tube for  suprapubic 
cystotomy.  ( Trende- 
lenburg. ) 


SPECIAL  APPLICATION  OF  THE  ASEPTIC  METHOD.        165 

ance  of  the  eye.  Removal  or  even  the  finding  of  the  encysted  calculi  would 
have  been  utterly  impossible  from  a  perineal  wound.  Weight  of  calculi,  one 
ounce,  five  drachms,  and  twenty  grains. 

Case  II. — Mr.  Adolph  "W.,  plumber,  aged  fiftj-six.  Vesical  trouble  of  three  years' 
standing.  Urine  slightly  acid,  turbid,  containing  much  pus,  but  no  casts.  March  30^ 
1887. — Exploration  of  the  very  irritable  bladder  with  the  stone-searcher  yielded  no 
positive  result.  April  18,  1887. — On  exploration  in  ether  anassthesia,  stone  was  found. 
A  Thompson  lithotrite  being  introduced,  a  large  stone  was  grasped,  and  on  rotation 
was  felt  to  grind  against  another  calculus.  Suprapubic  lithotomy.  Extraction  of  three 
stones,  each  weighing  about  forty-three  grammes,  their  aggregate  weight  being  four 
ounces  and  three  gi-ains  Troy  weight.  Ajjril  20th. — Temperature,  100"5°  Fahr. ;  urine 
clear,  acid,  containing  no  blood  ;  its  daily  quantity  eighty  ounces.  April  23(L. — Patient 
was  allowed  to  occupy  the  supine  position.  April  25th. — The  drainage-tube  was  with- 
drawn and  the  packing  removed.  A  soft  catheter  was  introduced  by  the  urethra,  and 
the  bladder  was  irrigated  through  it.  The  catheter  was  left  in  the  bladder;  the  ex- 
ternal wound  was  repacked.  Temperature,  98'5°  Fahr.  May  1st. — Thrombosis  of 
right  femoral  vein,  apparently  due  to  defective  circulation  caused  by  confinement. 
Tlie  right  lower  extremity  enormously  increased  in  size.  Treatment :  Elevated  post- 
ure; later  on,  moist  packing,  and  elastic  compression  by  Martin's  bandage.  May  25th. 
— Lithotomy  wound  nearly  closed  ;  passed  some  water  through  urethra.  June  Jfth. — 
Lithotomy  wound  closed;  urination  normal.  Patient  up  and  about  most  of  the  time; 
oedema  of  thigh  fast  diminishing.  June  20th. — Swelling  of  thigh  almost  gone ;  patient 
dischai'ged  cured.  July  25th. — General  condition  excellent.  Patient  entirely  recov- 
ered. 

Case  III. — Mr.  Meyer  B.,  liveryman,  aged  thirty-nine.  Symptoms  of  very  acute 
cystic  catarrh  of  four  months'  duration,  causing  the  loss  of  fifty  pounds  of  flesh. 
Almost  constant  desire  of  and  very  painful  micturition,  the  acid  urine  containing 
blood,  pus,  some  mucus,  uric  acid,  and  osalate-of-lime  crystals.  The  prostate  was 
very  painful  on  touch,  but  not  appreciably  enlarged.  The  patient  had  become  morphi- 
ophagous,  and  was  thoroughly  demoralized.  Stone  was  searched  for  unsuccessfully 
by  a  surgeon.  June  17,  1886. — Suprapubic  cystotomy  at  Mount  Sinai  Hospital.  No 
stone  was  found,  but  the  mucous  membrane  of  the  bladder  presented  a  most  marked 
state  of  hypersemia  and  thickening,  profusely  bleeding  at  the  slightest  touch.  The 
inflammation  was  most  pronounced  about  the  trigonum  and  the  neck  of  the  bladder, 
where  the  reddening  and  tendency  to  htemorrhage  were  most  intense.  Trendelen- 
burg's T-shaped  drainage-tube  was  inserted,  and  the  case  was  treated  in  the  lateral 
position.  The  cystic  irritation  ceased  at  once,  the  blood  and  pus  in  the  urine  dimin- 
islied,  and  morphine  was  discontinued.  July  17th. — The  patient  was  removed  to  his 
home,  where  he  made  a  rapid  and  perfect  recovery.  In  March,  1887,  a  slight  degree 
of  catarrh  of  the  neck  of  the  bladder  was  cured  by  irrigation  with  permanganate-of- 
potash  lotion.     The  patient  remained  well  ever  since  then. 


23 


PART    II. 


ANTISEPSIS. 


CHAPTER   VI. 


NATURAL   HISTORY  OF  IDIOPATHIC   SUPPURATION. 

SUPPURATION. 


TREATMENT   OF 


I.     THE    CAUSE    OF    SUPPURATION    OR    PHLEGMON. 

It  would  far  transcend  the  limits  of  these  essays  to  enter  into  a  detailed 
presentation  of  all  vegetable  organisms  known  to  lead  a  parasitic  existence 
in  the  living  human  body.  But  a  few  glimpses  into  this  new  world  of 
beings,  more  or  less  hostile  to  human  health  and  life,  may  be  welcome 
to  the  busy  practitioner,  who  lacks  time  or  opportunity  for  independent 
research. 

Rosenbach's  classical  investigations  have  revealed  the  fact  that  the  most 
common  source  of  suppuration  is  the  implantation  and  thriving  in  the  living 
human  tissues  of  a  minute  globular  fungus  or  micrococcus,  called  from  the 


Fig.  129. — Microscopical  as- 
pect of  staphylococcus  au- 
reus aad  aibus.  (Under 
the  microscope  their  ap- 
pearance is  identical.) 
(From  Rosenbach.) 


Fig.  130. — Streptococcus  pyogene 
(From  Kosenbach.) 


^♦8»ogfl»"* 


t 

Fig.  131.  —  Chain  -  coccus 
of  erysipelas  (Fehleisen). 
(From  Eosenbach.) 


Fig.  132.— 
trescence 
bach.) 


Bacillus  of  pu- 
(From  Eosen- 


Fig.  133. — Bacilli  taken  from  a  pu- 
trid bone-abscess  in  general  sepsis 
(962  diameters).  (From  Eosen- 
bach.) 


^ 


Fig.     134.  —  Bacilli     from 

emphysematous  gangrene. 
(From  Eosenbach.) 


golden  yellow  color  of  the  mold  it  forms  on  a  peptonized  meat-agar  culture- 
soil,  "Staphylococcus  pyogenes  aureus,''  or  the  golden  grape-coccus.  It  is 
called  grape-coccus  {staphyle,  grape)  on  account  of  the  agminated  or  bunched 
arrangement  of  the  single  cocci  that  compose  a  colony.     (Fig.  129.) 


170 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


This  coccus  is  found  in  almost  all  forms  of  acute  suppuration — in 
phlegmon,  glandular  abscesses,  and  in  acute,  infectious  osteomyelitis.  By- 
certain  methods  of  manipulation,  a  pure  or  unmixed  culture  of  this  fungus 
can  be  raised  upon  glass  plates  covered  with  a  film  consisting  of  a  mixture 

of  peptonized  meat-jelly 
and  agar  agar,  a  vegeta- 
ble form  of  gelatin.  This 
mold  resembles  in  struct- 
ure the  common  form  of 
mold  dreaded  by  house- 
keepers, only  it  has  a 
deep  orange  color.  It 
has  the  peculiarity  of 
thriving  upon  the  living 
human  tissues,  causing 
their  inflammation  and 
ultimate  death.  (Plate  I, 
Fig.  1.) 

Another  form  of  grape- 
coccus,  not  so  common 
as  the  preceding  one,  and 
apj)earing  either  alone  or 
associated  with  the  gold- 
en grape-coccus,  is  Eosen- 
bach's  "  Staphylococcus 
pyogenes  albus."  It  can  not  be  distinguished  from  the  yellow  coccus  under 
the  microscoj)e,  but  the  mold  produced  by  pure  culture  is  easily  recognized 
by  its  pearly  white  color.     (Plate  I,  Fig.  2.) 

Both  forms  of  grape-coccus  have  the  clinical  peculiarity  of  causing  well- 
localized  foci  of  phlegmon.  All  tissues  within  a  certain  area  become  uni- 
formly permeated  by  the  grape-coccus.  They  coagulate,  then  emulsify,  and 
the  result  is  a  distinct  abscess. 

Another  form  of  micro-organism — Kosenbach's  "  Streptococcus  pyogenes,^' 
ot: pus-generating  chain-coccus — is  so  called  on  account  of  the  arrangement 
of  the  single  globular  cocci  in  more  or  less  elongated  chains.  (Fig.  130.)  Its 
peculiarity  is  to  rapidly  extend  along  the  lymph-spaces  and  lymi^hatic  ves- 
sels. Its  emulsifying  property  is  not  as  pronounced  as  that  of  the  grape- 
coccus,  but  it  may  become  very  destructive  to  the  tissues  by  rapid  infiltra- 
tion along  the  lymphatics,  causing  progressive  gangrene.  The  peculiarity 
of  extending  along  the  course  of  the  lymph-vessels,  as  well  as  its  micro- 
scopical appearance,  testify  to  its  close  mori^hological  relation  with  the 
streptococcus,  or  chain-coccus  of  erysipelas,  discovered  by  Fehleisen.  (Plate 
I,  Fig.  3,  and  Plate  II,  Fig.  4;  then  Fig.  131.) 

Pure  cultures  of  the  pus-generating  streptococcus  and  the  coccus  of  ery- 
sipelas differ  very  distinctly  in  several  important  points  (see  Plate  II,  Figs. 
4  and  5),  but  microscopically  they  can  not  be  distinguished. 


135. — Bacilli  of  putrefaction  and  divei'se  forms  of  cocci 
in  putrid  blood.     (Koch.) 


Plate  I. 


Fig.  1. — Pure  culture  of  gold-colored  grape-coccus  of  suppuration  from  a  furuncle  of  the 

lip,  on  meat-peptone-agar,  seen  by  reflected  light. 
Fig.  2. — White  grape-coccus  by  reflected  light. 
Fig.  3. — Chain-coccus  of  pyaemia  by  reflected  light.    (Prom  Rosenbach.) 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION. 


171 


Xone  of  the  pus-geneniting  cocci  cause  what  is  commonly  called  putres- 
cence. Decomposition  of  tissties,  accompanied  by  the  production  of  foul 
odors,  is  always  due  to  the 
fermentative  action  of  di- 
verse forms  of  elongated  bod- 
ies, called  bacilli  or  bacteria. 
Plate  III,  Fig.  8,  shows  a 
pure  culture  of  the  ^^  Bacil- 
lus saprogenes,''  or  bacterium 
of  putrescence.  Fig.  9  is  a 
pure  culture  gained  from  an 
osteal  focus  in  putrid  com- 
pound fracture  with  fatal 
septicaemia.  (Figs.  132  and 
133.) 

The  accompanying  chro- 
molithographs were  careful- 
ly copied  from  Eosenbach's 
monograph,  and  give  a  very 
life-like  image  of  the  several 
molds  or  cultures. 

On    account    of    their   ex-      Fiq,  ise.— Bacteria  of  blue  pus  (TOO  diameters).     (Koch.) 

cellence  and  truthfulness,   a 

number  of  Koch's  renowned  microphotographs,  illustrating  various  forms 

of  microbial  growth,  have  been  here  reproduced. 


n.     PORTALS    OF    INFECTION. 

It  is  safe  to  assume  that,  without  exception,  all  forms  of  suppuration 
owe  their  origin  to  infection  from  without.     The  portals  through  which 

the   pyogenic   organisms 
P5^^ .  :■  -■  ^-:'?-:"^':  ^..-'n^T^'-^Li'-  ..'l-V\.>»^.'|      known  as  cocci  and  bac- 
teria   enter    the    system 
are,  on  one  side,  the  le- 
sions of  the  outer  integu- 
ment ;  on  the  other,  le- 
sions of  the  mucous  lin- 
ing of  the  digestory,  re- 
spiratory, and  urogenital 
apparatus.    The  infection 
of    larger  accidental    or 
surgical  wounds  has  been 
treated  of  in  the  preceding  chapters.     Infection  through  minimal  lesions  of 
the  skin  or  mucous  membranes  and  its  sequels  will  now  receive  attention. 

1.  Infection  through  Lesions  of  the  Skin.— The  popular  tenet  that  a 
wound  that  bleeds  well  heals  well,  is  based  on  correct  observation.     Sharp 


Fig.  137.— Human  kidney  in  pyelo-nephritis.     In  the  center, 
urinary  canal  filled  with  cocci  (700  diameters).     (Koch.) 


172  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

haemorrhage  is  very  apt  to  dislodge  and  carry  ofE  particles  of  filth  deposited 
in  the  wonnd  from  without  at  the  time  of  the  injury  ;  and,  further,  it  sig- 
nifies an  abundant  blood  supply,  good  nutrition,  hence  prompt  union.  An- 
other point  of  imi3ortance  is,  that  wounds  that  bleed  profusely  generally 
come  under  the  care  of  a  jjliysician.  and  will  receive  at  once  proper  atten- 
tion and  protection  from  further  injury. 

Small  abrasions,  lacerations,  or  punctured  wounds  that  bleed  very  little, 
or  not  at  all,  have  deservedly  a  bad  reputation.  If  the  injuring  instrument 
or  object  does  not  inoculate  the  wound  with  filth,  and  subsequent  infection 
is  prevented  by  proper  measures,  healing  will  proceed  without  interruption. 

But,  as  a  rule,  these  wounds  are  neglected  from  the  outset,  because  there 
is  scanty  or  no  haemorrhage.  The  sharp-edged  tool  of  the  mechanic,  or 
the  pointed  object  handled  in  the  daily  vocation  of  the  laboring  man,  is 
very  rarely  clean.  In  certain  occupations,  as  that  of  the  butcher,  anato- 
mist, or  cook,  the  hands  are  frequently  injured  while  in  contact  with  foul 
organic  substances,  and  the  injuring  force  will  at  the  same  time  inoculate 
filth.  No  haemorrhage  following,  and  the  pain  being  insignificant,  the 
matter  is  lightly  passed  over,  and  work  proceeds  without  interruption.  The 
cleansing  effected  by  haemorrhage  is  absent,  the  small  orifice  of  the  skin  is 
soon  filled  by  lymph  and  obliterated,  and  we  have  to  deal  with  a  hermetic- 
ally sealed  focus  containing  filth,  leavened  by  a  certain  number  of  micro- 
organisms, that  at  once  must  and  do  begin  to  develop  and  multiply,  causing 
a  destructive  purulent  inflammation. 

Not  all  of  these  small  injuries  are  infected  from  the  beginning.  They 
may  and,  as  their  frequent  spontaneous  healing  proves,  are  often  enough 
aseptic. 

As  a  matter  of  fact,  they  do  well  at  first,  and  as  long  as  the  patient  takes 
care  of  them.  But  if,  as  often  happens,  the  protecting  scab  is  reinjured, 
and  infection  by  contact  with  foul  matter  follows,  the  consequence  is  sup- 
puration. 

Note. — Inflammatory  lesions  of  the  skin  are  fruitful  sources  of  infection,  among  them 
eczema  the  foremost.  The  intense  itching  leads  irresistibly  to  scratching,  and  the  small  excoria- 
tions thus  produced  are  often  the  portals  of  infection. 

2.  Infection  through  Lesions  of  the  Mucous  Membranes. — Less  numerous 
than  the  lesions  of  the  skin,  yet  productive  of  frequent  mischief,  are  the 
traumatic  and  inflammatory  lesions  of  the  mucous  membranes.  Slight 
injuries  to  the  lips,  tongue,  buccal  and  faucial  mucous  membrane  are  very 
common.  In  most  cases  a  profuse  flow  of  saliva  is  instantly  jiroduced  by 
a  painful  injury,  and,  if  haemorrhage  be  also  present,  infection  rarely  takes 
place.  Healthy  oral  cavities  and  their  adnexa  are  especially  exempt  from 
infectious  processes  following  injuries.  Even  gunshot  wounds  of  these  parts 
can  heal  without  suppuration  under  favorable  circumstances  : 

Case. — E.  L.,  aged  eiphteon,  admitted  to  Mount  Sinai  Ilospita),  December  7,  1884, 
with  suicidal  fresh  pistol-shot  wound  of  the  tongue,  extending  from  the  tip  backward 
to  the  left  side  of  the  base,  dividing  the  organ  in  two  uiicfpial  ])nrt.s.    (Junshot  perfora- 


Fig.  4. — Culture  of  chain-coccus  from  a  ease  of  acute  progressive  gangrene. 

light. 
Fig.  5. — Chain-coccus  of  erysipelas  (Fehleisen).     Transmitted  light. 
Fig.  6. — Chain-coccus  of  erysipelas  by  reflected  light.     (From  Rosenbach.) 


Transmitted 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        173 

tion  of  tlie  ])illars  of  the  fauces  of  the  left  side ;  gunshot  wound  of  the  posterior  pharyn- 
geal wall,  tbe  point  of  entrance  situated  Just  bacl<  of  the  faucial  ])iilars  of  the  left  side, 
about  an  inch  and  a  quarter  from  the  median  line,  all  of  tliese  injuries  being  produced 
by  a  bullet  of  22  mm.  caliber.  A  second  non-penetrating  gunshot  wound  on  the  fore- 
head without  a  point  of  exit.  Free  hasmorrhage  from  the  tongue,  and  also  a  stream 
of  arterial  blood  fi-om  the  pharyngeal  wound.  The  latter  being  in  close  vicinity  to  the 
left  internal  carotid  artery,  the  left  common  carotid  was  tied  at  once  as  a  preventive 
measure,  mainly  with  a  view  to  the  possibility  of  subsequent  suppuration  and  second- 
ary hjBinorrhage.  The  perfect  condition  of  the  teetli  and  oral  mucous  membrane  was 
noted.  The  lingual  wound  was  lightly  rubbed  over  with  a  small  sponge  dipped  in 
iodoform-powder ;  the  pharyngeal  wound  teas  not  probed,  and  hourly  irrigation  of  the 
oral  cavity  with  weak  salt  water  was  practiced.  Profuse  sweating,  perhaps  due  to 
reflex  vasomotor  disturbance,  set  in,  and  persisted  for  about  forty- eight  hours.  The 
febrile  movement  was  very  slight,  and  both  the  operation  wound  and  the  gunshot 
wound  on  the  forehead,  being  redressed  on  December  15th,  were  found  healed  and 
dry  under  their  iodoform  dressings.  The  lesion  of  the  tongue  was  found  granulating 
and  contracting,  the  perforation  of  the  pillars  of  the  fauces  nearly  closed,  the  point  of 
entrance  in  the  posterior  pharyngeal  wall  firmly  occluded  by  a  fresh-looking  blood- 
clot.  Breath  odorless.  December  21st. — The  flattened  ball  removed  by  small  incision 
from  the  top  of  the  head,  where  it  could  be  felt  beneath  the  skin.  The  entire  track 
of  this  projectile  had  literally  healed  without  suppuration.  The  pharyngeal  wound 
found  also  cicatrized  over,  the  ball  being  imbedded  near  and  below  the  left  transverse 
process  of  the  atlas,  in  close  proximity  to  the  vertebral  and  internal  carotid  arteries. 
The  head  was  held  inclined  to  the  right  side,  erection  of  the  spine  and  its  flexion  to 
the  left  being  impossible  on  account  of  the  intense  pain  caused  by  the  attempt.  This 
functional  disturbance  diminished  to  such  an  extent  within  a  few  months  that  the  con- 
templated extraction  of  the  small  projectile  was  abandoned. 

Had  the  patient's  oral  cavity  been  foul  from  putrid  processes  accompany- 
ing an  acute  or  chronic  oral  catarrh,  due  to  dental  caries  or  other  causes, 
suppuration  of  the  pharyngeal  wound  would  have  been  very  probable.  The 
danger  would  have  been  very  much  graver  on  account  of  the  possibility  of 
extension  of  the  suppuration  and  the  likelihood  of  uncontrollable  secondary 
hfemorrhage.  A  probing  of  similar  wounds  without  a  clear  and  necessary 
object  in  view  is  cdways  a  dangerous  and  invariably  useless  step,  and  should 
be  refrained  from  under  almost  all  circumstances.  We  may  use  a  clean 
probe,  and  the  probe  may  not  be  the  carrier  of  infection  ;  but  its  introduc- 
tion will  break  down  the  blood-clot,  the  natural  barrier  provided  by  the 
organism  itself  against  infection,  and  the  probe  will  leave  behind  an  open 
channel  for  the  entrance  of  possibly  fetid  oral  mucus  into  the  narrow  wound. 

Next  in  frequency  to  the  inflammations  in  and  about  the  oral  cavity 
and  its  adnexa  are  those  due  to  injuries  and  other  lesions  about  the  anal 
and  uro-genital  orifices. 

III.     ENTRANCE,    PROGRESS,    AND    LOCALIZATION    OF    THE 

INFECTION. 

As  long  as  the  integrity  of  the  epidermis  is  preserved,  no  infection  from 
without  will  take  place.     The  integrity  of  the  epithelial  covering  of  the 
mucous  membranes  does  not  seem  to  have  the  same  protective  power  as  the 
24 


174 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


epidermis.  This  may  be  explained  by  the  fact  that  slight  injuries  of  the 
mucous  lining  are  i)roduced  much  more  easily  than  those  of  the  skin,  and 
are  not  readily  ascertained  on  account  of  the  normally  moist  condition  of 
the  parts. 

As  formerly  stated,  the  slightest  denudation,  not  deep  enough  to  cause 
ha?morrhage,  and  just  productive  of  a  slight  exudation  of  serum,  offers  a 
favorable  point  of  entrance  to  the  virus  in  the  patulous  orifices  of  the 
lymphatic  vessels  or  lymph-spaces,  thus  exposed  by  the  injury. 

In  lacerations  or  punctured  wounds  the  infective  agents  are  very 
often  deeply  inoculated  with  the  jDoint  of  the  injuring  article — that 
is,  they  are  at  once  deposited  in  close  vicinity  to  deejJ-seated  lymph- 
vessels. 

In  the  more  superficial  forms  of  injury,  the  implantation  of  the  virus 
occurs  only  in  the  neighborhood  of  more  superficial  lymphatics,  and  its 
transmission  to  the  deeper  lymph- vessels  is  accomplished 
by  forces  which  govern  the  flow  of  lymph  from  the  pe- 
riphery to  the  center.  Aside  from  the  normal  current  set- 
ting toward  the  thoracic 
duct,  external  forces  and 
the  play  of  the  volun- 
tary muscles  have  an  im- 
portant part  in  hasten- 
ing the  flow  of  lymph. 
So,  for  instance,  the 
pressure  exerted  upon 
the  lymphatics  of  the 
palm  by  the  frequent 
and  vigorous  grasping 
of  a  tool  "wielded  for  a 
long  time  with  great 
force,  will  undoubtedly 
help  to  propel  the  con- 
tents of  the  peripheral  lymphatics  toward  the  larger,  more  deeply  situated 
lymphatic  trunks.  Or  the  vigorous  contractions  of  the  muscles  during 
mastication  v^ill  undoubtedly  empty  the  adjacent  lymphatics  centerward, 
their  action  being  aptly  comparable  to  that  of  a  force-pump. 

What  was  formerly  denoted  as  external  mechanical  irritation  is  nothing 
but  this  forcing  of  pus-generating  substances  into  the  open  lymphatics  by 
friction  or  other  pressure  due  to  exercise. 

The  direction  and  extent  of  the  spread  of  the  infection  by  the  lymphatics 
are  prescribed  by  the  anatomical  arrangement  of  the  lymph-vessels  of  the 
region  concerned.  Thus,  on  the  palmar  aspect  of  a  finger,  the  poisoning 
will  rapidly  extend  to  the  periosteum,  as  the  lymphatics  all  tend  that  way. 
In  the  vicinity  of  lymph-glands,  the  infection  will  promptly  extend  to  them, 
an  intervening  lymphangitic  streak  often  clearly  denoting  the  route  by 
which  it  traveled. 


Fig.  138. 


-Bacilli  of  antlirax  and  streptococcus 
(700  diameters).     (Koch.) 


Plato  III. 


Fia.  7.— Mixed  culture  of  golden  and  lemon  colored  and  of  white  grape-coccus  from  a 

case  of  empyaemia.     Reflected  light. 
Fig.  8.— Common  organism  of  putrescence.     Bacillus  saprogenes.     Reflected  light. 
Fig.  9.— Bacillus  saprogenes   from  a    focus   of   septic    compound   fracture.     Septicfemia. 

Reflected  light.     (From  Rosenbach.) 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        175 

The  varying  intensity  of  the  infection,  dependent  on  hitherto  nnknown 
and  varying  fermentative  qualities  of  different  cultures  of  micro-organisms, 
will  also  greatly  influence  the  rapidity  and  virulence  of  the  inflammatory 
process.  So  much  is  well  established  that  the  intensity  of  the  infection 
depends, ^r^'^,  on  the  virulence  of  the  invading  culture  of  bacteria  ;  secondly, 
on  the  quantity  of  fungi  absorbed  ;  and,  thirdly,  on  the  i)ower  of  resist- 
ance— that  is,  the  state  of  health  of  the  invaded  organism. 

Mechanical  Irritation.  —  Mechanical  irritation  ly  foreign  substances 
imbedded  in  tissues,  such  as  bullets,  splinters  of  glass,  or  a  broken-off  point 
of  a  knife-blade,  is  also  a  myth  in  the  old  meaning  of  the  phrase.  They 
never  cause  suppuratio7i  unless  infectious  substances — that  is,  microbial 
filth — be  adherent  to  them  at  the  time  of  their  being  deposited  in  the  tis- 
sues. They  may  cause  pain  by  pressure  upon  nerves,  or  may  interfere 
with  the  play  of  a  Joint  or  a  muscle,  but,  as  a  rule,  never  will  cause  in- 
flammation or  suppuration.  Well-disinfected  steel  nails,  driven  by  mallet 
through  femur  and  tibia  after  exsection  of  the  knee-joint,  are  unhesitat- 
ingly left  imbedded  for  thirty  or  more  days,  never  causing  any  irritation 
(see  Exsection  of  Knee- Joint,  page  287.) 

Case. — In  1882  a  young  blacksmith  presented  himself  in  the  surgical  division  of 
the  German  Dispensary.  An  angular  foreign  body  could  be  distinctly  felt  under  the 
skin  on  the  palmar  aspect  of  the  right  forearm,  midway  between  elbow  and  wrist, 
causing  pain  by  impinging.  The  body  had  appeared  only  since  a  few  weeks.  Near 
the  carpus  a  transverse  cicatrix  was  to  be  seen,  and  the  patient  explained  that  he  was 
cut  there  during  a  drunken  brawl  two  years  ago,  and  that  a  surgeon  had  tied  an  artery 
and  sewed  up  the  wound,  which  had  healed  without  suppuration.  Ever  since  then  he 
had  worked  at  his  trade  without  any  inconvenience  until  within  a  few  days.  From 
the  incision  made  over  the  projecting  body,  a  blackened  knife-blade,  four  inches  long 
and  five  eighths  of  an  inch  wide,  was  extracted,  to  the  greatest  astonisliment  of  the 
patient.     The  small  wound  closed  promptly. 

Here  we  saw  a  massive,  sharp-edged  foreign  body  lie  imbedded  for  two 
years  between  the  muscles  of  the  forearm  without  any  inconvenience  to  the 
patient,  until  the  angular  base  of  the  blade  had  worked  out  under  the  skin. 
Why  did  it  not  cause  suppuration  ?  Apparently  the  blade  must  have  been 
newly  ground,  or  at  any  rate  very  clean,  when  it  broke  off  in  the  arm  of 
our  blacksmith.  Had  a  considerable  amount  of  infection  been  carried  along 
with  it  at  the  time  of  the  injury,  its  presence  would  not  have  been  over- 
looked so  long. 

Dead  organic  substances,  as,  for  instance,  blood,  or  cubes  of  animal  tis- 
sues, such  as  muscle,  tendon,  or  portions  of  liver  or  bone,  were  taken  from 
a  freshly  killed  animal,  and  introduced  into  the  abdominal  cavity  of  a  num- 
ber of  other  rabbits  under  strict  antiseptic  precautions.  In  a  very  large 
proportion  of  cases  no  reaction  whatever  followed.  The  animals  being 
killed,  it  was  found  that  blood  was  absorbed  outright ;  that  muscle,  liver, 
tendon,  and  bone  were  encapsulated  ;  and  that  their  structure  was  gradually 
invaded  by  granulation  tissue — disintegration  and  final  absorption  follow- 
ing after  a  while,  proportionate  to  the  density  of  the  implanted  bodies.     In 


176  RULES  OF   ASEPTIC  AND   ANTISEPTIC  SURGERY. 

cases  where  the  ordinary  asei^tic  measures  liad  been  omitted,  septic  purulent 
peritonitis  followed  as  a  rule. 

Note. — The  most  remarkable  of  Dr.  H.  Tillmaim's  experiments  (Yirchow's  "  Archiv,"  Bd. 
Ixxviii,  IS'TQ)  is  that  concerning  a  rabbit,  in  the  abdomen  of  which  an  entire  rabbit's  kidney  was 
deposited  without  causing  any  harm  whatever.  The  animal  being  killed  forty-seven  days  after 
the  operation,  the  implanted  kidney  was  sought  for  in  vain,  as  it  had  disappeared  by  absorption, 
the  only  vestige  of  its  former  presence  being  a  spot  of  tough  cicatricial  tissue,  denoting  the 
locality  where  the  foreign  body  was  attached  by  exudations. 

Tliis  experimental  observation  is  fully  borne  out  by  the  experience  gained 
in  numberless  ovariotomies,  where  massive  pedicles,  dead  through  stoppage 
of  their  circulation  by  ligature,  are  dropped  back  harmlessly  in  the  perito- 
naeum, to  be  finally  absorbed — that  is,  they  will  do  no  harm  if  a  culture 
of  bacteria  is  not  deposited  on  them  by  the  operator. 

Chemical  and  Caloric  Irritation. — The  common  experience  that  certain 
acutely  irritating  substances,  as,  for  instance,  croton-oil,  oil  of  cantharides, 
turpentine,  concentrated  solutions  of  corrosive  sublimate,  and  others, 
brought  in  contact  with  living  tissues,  always  would  produce  suppuration, 
represented  a  serious  gap  in  the  theory  of  the  microbial  origin  of  suppura- 
tion. If  invariably  proved,  it  would  be  more  than  a  defect,  as  it  would 
positively  contradict  the  thesis  that  suppuration  is  exclusively  and  always 
the  result  of  the  development  of  micro-organisms.  The  experiments  of 
Councilman,*  who  introduced  under  the  skin  of  animals  small  glass  globes 
filled  with  sundry  irritating  substances,  and  then  crushed  them,  all  led  to 
suppuration.  Scheuerlen  f  and  Klemperer,J  however,  in  going  over  Coun- 
cilman's experiments,  showed  that  his  procedure  was  faulty,  inasmuch  as 
sufficient  precautions  had  not  been  taken  to  exclude  the  introduction  of 
microbes  along  with  the  croton-oil,  etc.  They  moreover  positively  demon- 
strated by  a  very  large  number  of  successful  experiments  that,  whenever 
thorough  aseptic  cautelse  were  observed,  suppuration  never  followed  the  in- 
troduction of  even  very  considerable  quantities  of  the  mentioned  substances. 
Small  quantities  caused  some  exudation  of  plasm,  and  then  were  absorbed 
outright.  Afterward  the  fragments  of  the  glass  receptacle  were  found  im- 
bedded in  a  film  of  new-formed  connective  tissue.  Larger  quantities  of 
croton-oil,  for  instance,  caused  a  coagulation  necrosis  of  a  limited  mass  of 
tissue,  which  was  found  dense,  bloodless,  and  of  a  yellow  color.  These 
nodes  of  necrosed  tissue  were  gradually  absorbed,  suppuration  never  folloio- 
ing  the  experiment.  This  fact  is  in  full  accord  with  other  incontestable 
facts  of  the  same  character,  as,  for  instance,  the  absorption  of  necrosed 
ovarian  stumps  in  the  abdominal  cavity  if  there  be  no  microbial  infection 
present. 

Caloric  irritation,  or  even  an  outright  destruction  of  tissues  by  exces- 
sive heat,  presents  a  similar  state  of  things.  As  long  as  microbial  infection 
is  successfully  kept  away  from  the  exudations  in  burns  of  a  milder  charac- 

*  Virchow's  "Archiv,"  1883,  vol.  xcii,  p.  217. 

f  "  Archiv  fiir  klin.  Chirurgie,"  vol.  xxxii,  p.  500. 

\  Prize  es.say,  Berlin  University,  "Zeitschr.  fiir  klin.  ]\lcd.,"  1885,  vol.  x,  p.  158. 


NATURAL  HISTORY   OF  IDIOPATHIC  SUPPURATION.        177 

tcr,  and  from  the  eschar  and  exudations  in  severer  forms,  no  suppuration 
will  follow.  The  modern  use  of  the  thermo-cautery  in  the  peritoneal  cavity, 
in  joints,  and,  as  a  matter  of  fact,  in  wounds  of  the  most  various  character 
and  of  all  anatomical  regions,  is  followed  by  uninterrupted  union  in  all 
cases  where,  at  the  same  time,  adequate  aseptic  measures  are  employed. 
An  eschar  or  a  mass  of  dead  tissue,  whether  produced  by  ligature,  or  chemi- 
cal corrosion,  or  red  heat,  will  never  assume  the  irritating  character  of  a 
"foreign  body,"  in  the  meaning  of  the  term  as  presented  by  the  tenets  of 
an  older  pathology,  if  the  decomposing  action  of  the  presence  of  micro- 
organisms is  excluded  by  proper  measures. 

The  behavior  of  superficial  lurns  of  the  skin  is  fully  in  accord  with  the 
facts  Just  presented. 

If  a  bleb  be  raised,  and  is  left  unbroken  and  dry,  its  contents  will  be 
absorbed,  and  the  epidermis  will  settle  back  into  its  normal  relation  to  the 
cutis.  It  will  turn  into  a  dry  scale,  and  will  peel  off  within  ten  to  twelve 
days,  exposing  the  tender  new  epidermis. 

How  different  is  the  course  of  a  burn  if  the  epidermis  is  torn  off  by  .acci- 
dent or  intentionally,  and  the  exudations  are  thus  exposed  to  the  invasion 
of  micrococci  !  If  the  surgeon  do  not  emj^loy  timely  disinfection  and  the 
application  of  a  protective  dressing,  suppuration  of  the  exposed  cutis,  witli 
all  its  accompaniment  of  pain,  long-continued  granulation,  and  a  very  tardy 
healing,  will  follow. 

IV.     DEVELOPMENT    OF    PHLEGMON. 

From  the  moment  that  a  sufficient  quantity  of  active  fungi  have  estab- 
lished themselves  within  the  living  tissues,  remarkable  local  and  general 
phenomena  develop,  known  under  the  name  of  inflammatioji  and  septic 
fever. 

Our  object  is  not  research  into,  but  rather  a  lucid  explanation  of,  the 
essence  of  inflammation,  as  understood  and  accepted  by  contemporary  au- 
thorities. Hence  a  brief  sketch  of  the  leading  features  of  the  process  is 
deemed  sufficient. 

Micrococci  find  a  most  favorable  pabulum  in  dead  or  devitalized  organic 
substances.  The  living  tissues  offer  a  decided  resistance  to  the  ravages  of 
the  micro-organism.  The  spontaneous  limitation  and  occasional  unaided 
cure  of  some  forms  of  suppurative  inflammation  prove  this  assertion. 

Bacteria  can  not  thrive  on  the  products  of  decomposition  :  they  need 
for  their  sustenance  dead  but  undecomposed  albuminoid  substances.  As 
soon  as  the  supply  of  dead  animal  tissue  is  exhausted,  the  micro-organisms 
starve  and  perish.  Their  spores  or  seeds  are  left  behind  dormant,  but  will 
become  active  if  fresh  pabulum  is  offered  under  favorable  circumstances. 

This  explains  the  fact  that  fresh  cadavers  or  animal  substances  in  the 
recent  stages  of  putrescence  are  much  more  infectious  than  those  that  are  in 
a  progressed  state  of  decomposition.  The  varying  intensity  of  different  cases 
of  infection  seems  to  dej)end  in  a  great  measure  upon  the  varying  degrees 


178 


RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  vitality  of  ditferent  microbial  cultures.  It  seems  to  admit  little  doubt 
that  the  great  majority  of  dangerous  wound  infections  are  brought  about  by 
the  importation  of  considerable  masses  of  very  active,  rapidly  proliferating 
micro-organisms  in  the  shape  of  '^umps  of  dirt,"  as  Lister  graphically  puts 
it,  taken  from  various  sources  of  recent  putrescence,  so  abundant  in  all 
human  surroundings.  The  dry  spores  floating  in  the  air  will  be  easily  taken 
care  of  by  the  living  tissues,  if  pollution  of  the  wound  by  gross  dirt — that 
is,  masses  of  organic  matter  in  active  decomposition — is  avoided. 

Every  injury  causing  a  wound  destroys  the  vitality  of  those  cells  that 
lie  in  the  direct  path  of  the  cutting  or  lacerating  object.  The  blood  and 
lymph  exuded  from  the  vessels  coagulate,  and  also  represent  dead  matter. 

If  a  number  of  active  micrococci  are  implanted  into  the  bottom  of  the 
wound,  they  will  at  once  multiply,  using  the  blood-clot  and  its  extensions 
into  the  blood-vessels,  together  with  the  adjacent  dead  or  devitalized  tissues, 
as  a  welcome  soil  for  their  development.  This  fermentative  decomposition 
produces  from  its  very  beginning  certain  alkaloids  or  chemical,  extremely 
poisonous  substances,  the  ptomaines,  that  are  very  diffusible.  By  dint  of 
this  diffusibility,  the  adjacent  vasomotor  nerves  at  once  come  under  their 
toxic  influence,  as  the  result  of  which  their  strong  dilatation  ensues,  which 
becomes  manifest  in  the  shape  of  an  active  hypercemia,  "rubor.'''' 


S     €.  #J^ 


Fig.  13'.». — Bacilli  of  anthrax  (Iw  diameters). 
(Koch.) 


Fig.  140. — Formation  of  spores  in  anthrax 
bacilli  (700  diameters).     (Koch.) 


The  Ijlood  passing  through  the  adjacent  arterioles  and  capillaries  seems 
also  to  become  altered  ;  the  red  blood-corpuscles  become  packed  and  finally 
stagnate  in  the  capillaries  and  smaller  arteries.  The  walls  of  these  vessels, 
including  the  veins,  lose  their  impermeability,  and  a  number  of  white  and 
often  red -blood-corpuscles  emigrate  into  the  surrounding  tissues,  densely 
infiltrating  their  interstices,  thus  producing  the  characteristic  sivelling, 
"turgor.'^ 

As  a  consequence  of  the  increased  blood-supply,  possibly  also  of  the 
active  chemical  i)roccss,  a  marked  increase  of  the  local  temperature  is  ob- 
served— "calor.''     And,  if  we  add  that  pain  of  the  parts  thus  affected  is 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        1Y9 

never  absent,  we  have  completed  the  classical  cycle  of  the  four  cardinal 
sym])touis  of  inflammation — ''rubor,  calor,  turgor,  dolor. ''^ 

Note. — The  causes  of  local  pain  may  be  several.  The  initial  pain  is  very  likely  due  to  a 
direct  influence  of  the  ptomaines  upon  the  sensory  filaments.  Direct  pressure  caused  V)y  the 
dense  infiltration  may  also  have  some  influence ;  but  the  most  acute  pain  is  undoubtedly  effected 
by  the  actual  destruction  of  the  nerve-tissue  during  the  advanced  stages  of  suppuration. 

Stagnation  and  dense  infiltration  finally  produce  a  very  high  degree  of 
tension,  leading  to  compression  of  larger  afferent  vessels.  The  infiltrated 
portions,  devitalized  by  suppression  of  the  normal  circulation,  readily  suc- 
cumb to  the  inroads  of  the  millions  of  micro-organisms,  and  actual  necrosis 
raj^idly  follows.  The  last  stage  of  textural  destruction  is  the  final  liquefac- 
tion of  the  tissues  and  infiltrating  leucocytes,  aided  by  the  exudation  of 
large  quantities  of  lymph-serum  from  the  adjacent  unobstructed  blood-ves- 
sels, and  thus  the  formation  of  an  abscess  or  a  cavity  filled  with  lymph- 
serum,  myriads  of  dead  white  blood -corpuscles  (jius-cells),  and  quantities  of 
shreds  of  necrosed  tissues,  is  accomplished. 

The  veins  also  participate  in  the  disturbance.  Coagulation  of  their  con- 
tents— thrombosis — takes  place,  and  existing  stagnation  is  materially  aug- 
mented. 

The  deleterious  part  played  by  thrombi  in  the  causation  of  metastases 
will  be  later  mentioned. 

When  a  septic  inflammation  of  sufficient  exteiit  and  intensity  has  been 
well  advanced,  the  great  tension  of  the  parts  will  necessarily  cause  an  over- 
flow of  the  most  diffusible  contents  of  the  focus  into  the  surrounding  effer- 
ent vessels — the  veins  and  lymphatics.  The  ptomaines,  thus  entering  the 
general  circulation,  will  at  once  produce  systemic  intoxication,  manifested 
by  a  very  marked  rise  of  the  body-heat,  rigors,  sickness,  headache,  delirium, 
and  general  dejection — in  short,  a  deep-going  alteration  of  the  nervous 
system,  known  as  septic  fever. 

V.     SPREAD    OF    SUPPURATION. 

The  way  of  the  extension  of  septic  textural  destruction  is  twofold.  It 
takes  place,  ^rs^,  by  a  direct  infiltration  of  the  tissue-interstices  by  columns 
and  hosts  of  the  immensely  prodigious  micrococci — that  is,  by  an  immedi- 
ate growth  and  extension  of  the  microbial  colony  ;  and,  secondly,  on  the 
way  of  the  lymphatics,  openly  communicating  with  the  focus  of  suppura- 
tion. Into  these,  bacterial  masses,  or  pus  charged  with  micrococci,  are 
forced  by  the  hydrostatic  pressure  exerted  by  the  tension  within  the  abscess. 

If  the  parts  affected  are  composed  of  loose  tissues,  the  spread  will  be 
rapid  and  extensive ;  if  the  parts  are  dense,  the  inflammation  will  remain 
localized  as  long  as  the  density  of  the  tissues  (fasciae,  for  instance)  will  resist 
the  pressure  of  the  secretions.  But,  as  above  mentioned,  this  very  pressure, 
or  tension,  involves  another  great  danger.  The  afferent  blood-vessels  become 
thereby  occluded,  and  the  resulting  stagnation  generally  leads  to  extensive 
necrosis. 


ISO  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

As  long  as  new  areas  of  tissue  become  infected  through  the  lymphatics, 
constant  high  fever  and  increase  of  the  local  symptoms  is  the  rule.  An 
incision  laid  through  the  parts  at  an  initial  stage  of  the  process  will  expose 
a  honeycombed  mass  of  tissue,  containing  a  number  of  small  foci,  some  of 
them  confluent,  and  all  filled  with  pus,  the  intervening  substance  being- 
discolored,  i^ale,  or  more  or  less  broken  down  and  softened,  or  sloughed. 

In  direct  proportion  with  the  spread  of  the  infection  and  the  multiplica- 
tion of  suppurating  foci,  is  the  magnitude  of  necrosing  areas,  occasionally 
involving  an  entire  limb.  Organs  of  scanty  vascularity,  as,  for  instance, 
fascia?,  tendons,  and  bone,  are  the  first  to  succumb. 

The  microbial  colony  begins  to  show  signs  of  exhaustion  in  most  cases 
after  a  more  or  less  prolonged  period  of  florescence.  The  parasite  becomes 
less  prolific  ;  its  direct  ingrowth  into  the  tissues  is  less  and  less  active,  and 
the  life  of  the  white  blood-corpuscles,  densely  infiltrated  into  the  marginal 
parts  of  the  abscess,  is  not  compromised  by  their  invasion  with  micrococci. 
They  are  not  converted  into  pus,  but  withstand  the  attack  of  the  parasites 
and  remain  a  mass  of  embryonal  connective  tissue,  that  forms  a  dense  wall 
inclosing  the  suppurating  cavity.  This  embryonal  connective  tissue  uni- 
formly permeates  all  the  adjacent  parts,  among  others  the  lymphatics  and 
thrombosed  veins,  forming  a  more  or  less  effective  harrier  to  the  extension  of 
the  septic  process  and  to  the  absorption  of  deleterious  soluble  substances  into 
the  general  circulation. 

This  self-limitation  of  the  spread  of  septic  destruction  is  generally 
marked  by  a  remission  of  the  intensity  of  the  general  and,  in  a  measure,  of 
the  local  symptoms.  At  this  stage,  according  to  ancient  notions,  the  abscess 
has  matured. 

Note  I. — For  obvious  reasons,  the  incision  of  a  matured  abscess  is  generally  followed  by  a 
rapid  healing  of  the  cavity.  The  detachment  and  liquefaction  of  the  contents  of  the  abscess  are 
well  completed,  the  extent  of  the  process  is  well  rounded  off,  as  it  were,  by  the  wall  of  newly 
organized  connective  tissue,  and  repair  can  commence  under  favorable  circumstances. 

Nevertheless,  it  must  be  strongly  urged  that  the  most  dangerous  abscesses  never  I'ipen — that 
is,  show  no  tendency  to  self-limitation — and  that  the  measures  ordinarily  employed  for  maturing 
them,  such  as  vigorous  poulticing,  only  tend  to  intensify  their  malignity,  and  to  cause  irrepara- 
ble damage,  that  an  early  incision  might  have  averted.  A  case  vividly  illustrating  the  pernicious- 
ness  of  thoughtless  poulticing  is  quoted  on  page  234. 

Note  II. — Not  every  bacterial  infection  leads  to  suppuration,  although  the  rule  suffers  very 
few  exceptions  indeed.  One  of  the  exceptions  is  illustrated  by  the  following :  Case. — I.  N.,  laborer, 
aged  twenty-four,  was  admitted  to  the  German  Hospital  in  March,  1885,  with  a  very  painful, 
hard,  and  massive  swelling  of  the  axillary  contents,  the  skin  being  cedematous  and  angry-looking. 
High  fever  and  a  good  deal  of  sickness  were  observed,  so  that  pus  was  thought  to  be  indubita- 
bly present.  An  incision  was  declined,  whereupon  a  poultice  was  ordered,  with  the  expectation 
that  it  would  hasten  the  process  by  stimulating  suppuration.  For  a  day  or  two  the  intensity  of 
the  symptoms  increased  rather  than  otherwise,  several  sharp  chills  followed  with  profuse  sweat- 
ing, after  which  came  a  marked  improvement  of  all  the  appearances  of  the  case.  The  redness 
and  swelling  diminished,  the  fever  disappeared,  and  the  patient  left  the  hospital  cured,  glorying 
in  his  triumph  of  endurance  over  diagnostic  acumen. 

To  explain  such  cases,  it  is  necessary  to  assume  that,  under  the  powerful  stimulation  of 
the  local  circulation  by  the  cataplasm,  the  products  of  bacterial  fermentation,  bacteria,  or  even 
pus  itself,  are  washed  away  by  the  lymph-current  into  the  general  circulation,  where  the  pto- 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        ISl 

maines  provoke  constant  or  exploitive  symptoms  of  general  intoxication,  such  as  high  fever  or 
severe  chills ;  the  bacteria  themselves,  however,  perish,  the  living  oxidized  blood  forming  an 
unfavorable  pabulum  for  their  existence  and  piopagation.  In  accord  with  this  theory  is  the 
well-known  fact  that  wounds  of  very  vascular  tissues,  such  as  those  of  the  face,  for  instance, 
will  heal  without  suppuration  even  when  there  is  a  good  deal  of  inflammation  of  their  edges, 
with  pain  and  fever,  denoting  the  presence  of  a  certain  amount  of  septic  infection.  The  poorer 
the  blood-supply  of  a  part,  the  greater  the  destruction  wrought  by  an  infectious  process. 

If  the  abscess  is  not  evacuated  at  the  stage  of  maturity  through  a  fortu- 
nate spontaneous  or  an  artificial  opening,  the  relief  felt  by  the  patient  will 
be  a  short-lived  one.  The  marginal  wall  of  embryonic  connective  tissue — 
that  is,  the  area  of  granulations — will  continue  to  shed  lymph  and  detached 
leucocytes  into  the  abscess  cavity.  The  intramural  pressure  will  steadily 
increase  until  it  rises  to  such  a  degree  as  to  overcome,  on  hydrostatic  prin- 
ciples, the  resistance  of  the  soft  plugs  of  living  leucocytes,  which  occlude 
the  orifices  to  the  adjacent  connective-tissue  planes  and  lymphatics  or  veins. 
One  or  another  of  these  offering  the  least  resistance,  will  be  forced  out  of 
the  way,  and  a  new  invasion  of  hitherto  unaffected  regions  results,  with  a 
repetition  of  all  the  initial  local  and  general  symptoms,  marking  an  exten- 
sion of  the  jjrocess. 

Note. — The  notion  that  the  law  of  gravity  alone  regulates  the  spread  of  abscesses  is  an  erro- 
neous one,  as  it  is  *ell  known  that  many  forms  of  suppuration  extend  in  a  diametrically  opposite 
direction  to  the  force  of  gravity.  The  local  spread  is  prescribed  by  the  direction  of  the  loose 
connective-tissue  planes  separating  and  connecting  the  difPerent  organs,  and  is  mainly  influ- 
enced by  hydrostatic  law.     Perforation  always  takes  place  where  resistance  is  the  least. 

The  infiltration  of  the  tissues  by  micrococcal  colonies  sometimes  extends 
to  the  close  vicinity  or  into  the  very  walls  of  larger  veins.  Thrombosis  is 
the  direct  result,  and,  if  the  microbial  invasion  includes  the  thrombus,  after 
the  detachment  of  the  slough  of  the  vein  and  the  liquefaction  of  the  throm- 
bus, a  direct  communication  of  the  general  circulation  with  the  abscess 
cavity  may  be  established.  The  slightest  external  pressure  may  serve  to 
throw  enormous  masses  of  pus  and  micro-organisms  into  the  general  circula- 
tion at  this  critical  period,  causing  rapid  death  by  explosive  septicaemia. 
In  these  cases  the  microscope  will  demonstrate  the  presence  of  micrococci 
in  the  entire  blood-mass. 

In  other  cases,  either  spontaneously  or  in  consequence  of  active  move- 
ments or  external  manipulations,  a  portion  of  a  septically  infected  thrombus 
may  be  detached.  The  blood-current  will  at  once  carry  it  into  the  right 
auricle  and  ventricle,  whence  it  will  find  its  way  into  one  or  another  branch 
of  the  pulmonary  artery,  to  be  there  arrested  in  the  shape  of  an  embolus. 

Around  this  a  hsemorrhagic  infarction  of  the  adjacent  pulmonary  tissues 
will  form,  within  which  a  new  bacterial  colony  will  become  established, 
leading  to  the  formation  of  a  secondary  or  metastatic  abscess.  Its  appear- 
ance is  always  signalized  by  a  severe  rigor. 

Thrombosis  of  adjacent  pulmonary  veins,  and  detachment  of  portions  of 
the  new  thrombus,  followed  by  its  transportation  into  the  left  side  of  the 
heart,  and  hence  into  distant  smaller-sized  arteries  of  the  body,  will  lead  to 


182  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  repetition  of  the  metastatic  process  and  its  febrile  accompaniment,  until 
a  number  of  joints,  lymph-glands,  the  liver,  in  fact,  almost  all  the  organs, 
become  the  seat  of  secondary  abscesses. 

This  is  the  classical  type  of  well-develoj)ed  pycemia,  formerly  so  common 
in  all  surgical  hospital  wards,  but  now  become  a  rare  phenomenon  wherever 
the  leaven  of  the  Listerian  spirit  has  permeated  surgical  practice. 

This  form  of  microbial  colonization  of  the  entire  human  body  baffles 
every  plan  of  treatment,  and  almost  invariably  leads  to  the  destruction  of 
the  organism.  It  is  as  good  as  incurable,  hut  it  can  he  prevented ;  hence  it 
is  the  moral  duty  of  every  physician  to  do  everything  in  his  power  to  avert 
this  form  of  mischief. 

Note. — Recovery  of  a  case  of  well-developed  pycemia  is  so  rare  that  recording  the  following 
case  seems  permissible.  The  notes  were  kindly  furnished  by  Dr.  A.  Caille,  with  whom  the 
author  saw  the  patient  in  consultation  at  his  home  in  Williamsburg : 

"  Henry  Huhn,  an  elderly  man.  Enormous  carbuncle  over  left  scapula ;  necrosis  of  fasciae 
and  subcutaneous  connective  tissue  from  clavicle  to  seventh  rib  posteriorly,  the  result  of  three 
weeks'  neglect  (poulticing). 

"Energetic  treatment  (by  Dr.  Caille)  with  knife  and  irrigation  (carbolic).  Well-marked 
symptoms  of  pyemia ;  general  furunculosis  of  trunk. 

'■^August  16, 1880. — Consultation  with  Dr.  Gerster,  who  advised  tonic  treatment  and  daily 
full  hatJis  in  vieak  bichloride-of-mercury  solution,  together  with  frequent  irrigations  with  cam- 
phorated water.  Temperatures  at  this  time  on  an  average  102°  Fahr.  Pulse,  120  to  140.  Dysp- 
noea, chills,  and  sweats.  Improvement  noticeable,  but  slow.  In  Septembei",  suppuration  of 
almost  all  the  lymph-glands  took  place  within  one  week,  without  redness  or  tenderness,  so  that 
at  one  time  a  tenotomy  knife  introduced  almost  anywhere  would  draw  pus.  Subsequently  exten- 
sive and  painful  periostitis  and  abscess  at  upper  third  of  right  tibia  developed.  About  this  time 
examination  of  urine  revealed  a  large  percentage  of  sugar.  The  patient's  diet  was  properly 
regulated,  and  his  urine  was  free  from  sugar  five  months  later.  Mr.  H.  has  since  been,  and  is 
to-day  (December  23,  1886),  in  excellent  health." 

It  will  be  noticed  that  a  methodical  use  of  a  mercuric  lotion  was  advised  by  the  author  sev- 
eral years  before  Kuemmel's  and  Schede's  experiments  brought  corrosive  sublimate  so  promi- 
nently to  the  notice  of  the  medical  world  as  an  excellent  disinfectant.  The  recommendation 
was  based  upon  the  long-known  good  influence  that  corrosive  sublimate  has  upon  acne  pustu- 
losa  of  the  face.  Its  application  in  the  shape  of  a  full  bath  suggested  itself  by  the  extension  of 
the  affection  to  almost  the  entire  skin,  and  by  the  enormous  difficulty  in  cleansing  and  dressing 
the  innumerable  sores  of  the  patient.  Since  that  time  the  author  has  employed  the  permanent 
hath  in  another  similar  case,  to  the  great  relief  of  the  patient  and  his  attendants.  Twice  daily 
the  bath  was  charged  with  corrosive  sublimate  (1  :  5,000)  for  an  hour,  after  which  the  solution 
was  drawn  off,  and  substituted  with  a  weak  salicylic  lotion.  The  remarkable  relief  brought 
about  by  the  immersion  of  the  entire  body  was  due  to  the  circumstance  that,  first,  the  frequent 
and  extremely  painful  change  of  dressings  could  be  dispensed  with ;  and,  secondly,  that,  accord- 
ing to  hydrostatic  law,  the  buoyancy  of  the  immersed  body  relieved  to  a  very  great  extent  its 
pressure  upon  the  couch  spread  in  the  bottom  of  the  bath-tub.  The  spread  of  the  bed-sores 
ceased.  Before  his  attack,  the  patient  had  been  in  very  weak  health.  After  three  or  four  seiz- 
ures by  collapse,  relieved  by  increase  of  the  temperature  of  the  bath  to  110°  Fahr.,  he  suc- 
cumbed to  heai-t  failure. 

The  contents  of  the  preceding  pages  have  in  a  rough  way  illustrated  the 
essence  of  cellular  phlegmon,  or  the  suppuration  of  connective  tissue,  inele- 
gantly denoted  in  text-books  as  "cellulitis.'" 

For  obvious  reasons  lymphatic  glands  very  often  become  the  seat  of 
microbial  proliferation.     Their  direct  communication  with  a  numerous  set 


NATURAL  HISTORY  OF  IDIOPATHIC  SUPPURATION.        1S3 

of  lymi)liatics  and  their  filter-like  structure  naturally  lead  to  ready  absorp- 
tion and  detention  of  noxious  substances.  In  this  characteristic  is  to  be 
sought  a  by  no  means  insignificant  protective  quality  of  the  lymphatic 
glands  against  general  invasion  of  the  body  by  microbial  masses. 

The  dilference  exhibited  by  lymph-gland  abscesses  in  comparison  with 
the  ordinary  forms  of  phlegmon  is  due  to  their  anatomical  structure  and 
situation.  Their  strong  capsule  will  resist  destruction  for  a  comparatively 
long  time,  thus  preventing  for  a  while  invasion  of  the  vicinal  tissues.  But 
the  internal  tension  of  a  glandular  abscess  soon  becomes  very  great,  and  will 
lead  to  extensive  mortification  by  compression  of  vessels. 

The  anatomical  situation  of  many  lymph-gland  abscesses,  their  deep  seat 
and  close  vicinity  to  large  vessels,  the  pleura,  the  fauces,  and  larynx,  invest 
them  with  additional  importance,  both  as  regards  the  danger  peculiar  to 
their  locality,  and  the  technical  difficulty  of  their  treatment. 

The  sTceJeton  is  fortunately  a  comparatively  rare  seat  of  bacterial  infec- 
tion. The  fearfully  dangerous  and  destructive  character  of  acute  infectious 
osteomyelitis,  or  "bone  phlegmon,"  is  due  to  the  rigidity  and  unyielding 
nature  of  the  periosteum  and  bone  tissue,  which  lead  to  rapid  occlusion  of 
the  blood-vessels,  and  extensive,  often  widely  disseminated  necrosis.  The  deep 
situation  of  the  bones  renders  the  symptoms  of  this  form  of  suppuration  ex- 
tremely violent  and  dangerous,  and  increases  the  difficulties  of  treatment. 

XoTE  I. — The  so-called  habituation  of  butchers,  cattlemen,  and  anatomists  to  infection  seems 
to  be  based  rather  on  structural  changes  of  the  skin  of  their  hands  frequently  exposed  to  con- 
tamination, than  to  a  real  habituation,  such  as  is,  for  instance,  brought  about  by  vaccination 
against  the  small-pox.  That  the  system  of  these  persons  does  not  become  hardened  or  accus- 
tomed to  the  septic  virus  is  proved  by  the  fact,  that  phlegmonous  processes  will  readily  establish 
themselves,  and  develop  in  the  ordinary  way,  if  the  infection  occur  elsewhere  than  on  t/ieir  hands. 
A  more  plausible  explanation  of  this  apparent  immunity  will  be  found  in  the  state  of  the  lym- 
phatics of  the  integument.  Having  been  the  seat  of  frequent  more  or  less  intense  attacks  of 
inflammation,  they  become  obliterated  and  distorted,  as  it  were,  by  cicatricial  changes  in  and 
around  them.  That  recent  or  old  cicatricial  formations  do  not  possess  large-sized  lymph-vessels 
is  well  known,  hence  absorption  through  them  of  corpuscular  elements  into  the  deeper  lymphatics 
will  be  difficult  and  scanty.  In  short,  the  chronically  inflamed  state  of  the  skin  covering  the 
hands  of  these  persons  offers  in  its  infiltrated  condition  an  effective  protection  against  the  deep- 
going  or  massive  implantation  of  micro-organisms  through  superficial  lesions. 

Parallel  with  this  state  of  things  seems  to  be  the  well-known  fact  that  children  subject  to 
frequent  attacks  of  septic  tonsillitis  or  diphtheria  rarely  succumb  to  the  disease.  Penetration 
by  bacterial  elements  of  the  dense  cicatricial  tissue  left  behind  by  many  preceding  attacks  it- 
difficult,  and  absorption  of  the  ptomaines  through  the  scanty  lymphatics  is  very  limited.  Hence 
the  process  soon  becomes  exhausted  through  lack  of  pabulum  lo  the  microbial  growth.  A  cer- 
tain quantity  of  viable  spores  remain  imbedded  in  a  follicle,  to  again  develop  their  activity  as 
soon  as  a  simple  catarrhal  inflammation  of  the  pharynx  will  have  prepared  the  soil  for  their 
renewed  growth. 

Diphtheria  in  children  who  never  had  been  subject  to  the  disease  is  a  much  more  serious 
matter.  Unchanged  tissues  with  open  lymphatics  are  attacked  here.  The  conditions  for  local 
microbial  proliferation  and  invasion  of  the  tissues,  and  for  absorption  and  systemic  intoxication, 
are  much  more  favorable  then,  and,  as  is  well  known,  often  lead  to  unavertable  death. 

The  comparative  safety  of  all  operations  performed  within  the  limits  of  a  preceding  but 
terminated  inflammation — that  is,  within  recent  or  older  cicatricial  tissue — is  very  well  known 
to  all  surgeons.     Reamputations,  many  joint  exsections,  almost  all  necrotomies,  rarely  give  any 


184  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

serious  trouble,  even  if  the  antiseptic  measures  taken  were  not  very  complete.  The  infection 
of  an  amputation  wound  made  through  healthy  tissues  is  much  more  serious,  and  its  avoidance 
more  difficult,  as  countless  lymphatics  and  large,  newly  opened,  intermuscular,  loosely  knit 
connective-tissue  planes  offer  numerous  recesses  and  countless  channels  for  the  reception  and 
unimpeded  extension  of  infection. 

Therefore  the  statistics  of  amputation  wounds  have  been  very  appropriately  selected  as  a 
uniform  and  reliable  test  of  the  value  of  the  different  forms  of  wound  treatment. 

Note  II. — Infection  through  minute  injuries  to  a  granulating  surface  by  inoculation  of  active 
micrococci  is  the  frequent  cause  of  suppurations  interrupting  the  course  of  repair.  Rough  treat- 
ment of  a  granulating  wound  by  tearing  off  the  adherent  dressings  will  necessarily  lacerate  the 
tender  granulations  matted  into  the  meshes  of  the  fabric,  thus  causing  minimal  haemorrhage. 
If  an  unclean  probe,  or  finger-nail,  or  nitrate-of -silver  stick,  previously  used  on  a  virulent  case, 
and  then  applied  to  the  granulations,  should  carry  and  deposit  some  active  micrococci  into  one 
of  these  minute  lesions,  an  ulcerative  process  of  the  granulations  will  ensue,  and,  if  the  ulcera- 
tion extend  into  adjacent  tissues,  phlegmon  will  develop.  Granulations  should  ahvays  be  covered 
by  '■''protective''''  before  the  application  of  gauze  or  other  dressings. 

Conclusions. 

Suppuration  is  always  undesirable  and  dangerous,  and,  if  possible,  should 
be  avoided  by  all  means.  Its  essence  is  textural  destruction  and  death,  and 
systemic  intoxication.  The  phrase  '^healing  iy  suppuration  "  is  an  absurd- 
ity, is  misleading  to  the  student,  and  should  be  banished  from  text-books. 
As  a  matter  of  fact,  healing  never  takes  place  while  active  suppuration  lasts  ; 
it  occurs  only  after  the  limitation  and  termination  of  suppuration,  not  iy 
it,  hut  in  spite  of  it. 

The  expression  "laudable  pus,"  as  api)lied  to  the  contents  of  an  abscess 
during  one  of  its  stages  of  spontaneous  limitation  or  maturing,  is  also  mis- 
leading. Pus  is  never  laudable  ;  it  always  is  a  menace  to  the  health  and 
integrity  of  the  animal  organism.  Suppuration  is  a  treacherous  ally,  and 
its  aid  should  never  be  invoked  by  the  modern  surgeon,  or  at  least  should 
be  shunned  as  long  as  other  ways  of  curing  an  ailment  remain  untried. 

VI.     DIAGNOSIS    AND    TREATMENT    OF    PHLEGMON. 

1.  General  Principles. 

The  way  to  the  cure  of  phlegmonous  processes  is  indicated  by  the  man- 
ner in  which  unaided  nature  occasionally  accomplishes  it.  If  the  direction 
in  which  suppurative  destruction  progresses  should  luckily  be  outward — 
that  is,  toward  the  skin — perforation  and  spontaneous  evacuation  of  the 
abscess  cavity  will  occur.  If  by  another  lucky  accident  this  perforation 
should  happen  at  the  time  of  ''maturity,"  or  the  comparative  repose  of  the 
destructive  process,  a  complete  evacuation  of  the  deleterious  contents  will 
take  place,  followed  by  a  decreasing  sero-purulent  and  bland  discharge,  and 
by  contraction  and  final  occlusion  of  the  cavity. 

But  nature  unaided  is  a  very  poor  surgeon.  Very  often  destruction 
does  not  tend  toward  the  skin  ;  its  natural  tendency  is  to  spread  in  the  di- 
rection of  least  resistance,  that  is,  along  the  cellular  tissue,  and,  by  the  time 
that  spontaneous  openings  establish  themselves,  the  damage  to  deep-seated 


DIAGNOSIS  AND  TREATMENT  OF   PHLEGMON.  185 

organs  may  be  very  extensive.  The  coincidence  of  maturity  and  perforation 
is  also  rare.  In  its  absence  the  perforation  will  not  lead  to  complete  evacua- 
tion, and  the  septic  process  will  persistently  extend  in  one  or  another  direc- 
tion, not  relieved  by  such  incomplete  drainage.  Lastly,  natural  drainage  by 
perforation  will  often  be  located  in  the  most  unfavorable  place,  and  will  not 
be  ample  enough  for  the  escape  of  large  masses  of  pus  and  of  sloughing  tissue. 

The  most  direct  indications  for  the  cure  of  phlegmon  are  offered  by  a 
clear  understanding  of  the  natural  history  of  its  causation  and  development, 
as  presented  in  the  foregoing  pages. 

One  or  more  propei'ly  made  incisions,  folloioed  hy  effective  drainage,  will 
at  once  empty  the  focus  of  most  of  its  infectious  contents,  relieving  at  the 
same  time  the  dangerous  amount  of  tension. 

Infected  tissues  not  yet  liquefied,  and  still  adherent  to  the  walls  of  the 
abscess,  must  be  disinfected  by  more  or  less  frequent  or  permanent  irriga- 
tion with  a  germicidal  lotion.  Finally,  all  conditions  tending  to  impede 
free  arterial  and  venous  circulation  must  be  eliminated  by  proper  position 
— that  is,  elevation  of  limbs,  removal  of  constricting  dressings  or  clothing. 

The  necessity  of  rest — that  is,  the  avoidance  of  all  mechanical  injury — 
is  a  matter  of  course. 

{a)  Superficial  Suppuration,  or  Septic  Ulcer. — Inspissation  of  the  dis- 
charges of  an  infected  superficial  lesion  will,  by  the  formation  of  a  crust, 
often  prevent  proper  drainage,  causing  a  more  or  less  complete  occlusion 
or  retention.  The  gentlest  way  of  detaching  these  is  by  the  application  of 
a  warm  dressing  of  gauze  moistened  with  a  two-per-cent  solution  of  carbolic 
acid,  evaporation  of  which  should  be  guarded  against  by  an  external  layer 
of  rubber  tissue  or  oiled  silk.  After  due  softening  under  this  warm,  moist 
dressing,  the  overlapping  epidermidal  masses,  hiding  small  recesses,  should 
be  laid  open  by  cautiously  clipping  away  their  undermined  edges  with  curved 
scissors.  This  can  he  done  witliout  causing  the  least  pain.  Thorough  dis- 
infection by  the  lotion  contained  in  the  dressings  will  thus  be  possible,  and 
the  diffusible  qualities  of  carbolic  acid  will  not  fail  to  exert  their  beneficial 
disinfecting  influence  upon  the  germs  scattered  through  the  vicinity  of  the 
ulcer.  Its  yellow  coating,  consisting  of  a  superficial  layer  of  mortified  tis- 
sues, will  be  cast  off,  the  angry  look  of  the  neighboring  skin  will  disappear, 
and  the  remaining  healthy  granulations  will  soon  be  cicatrized  over. 

Streaks  of  lymphangitis  extending  toward  the  pertinent  lymphatic  glands 
should  be  well  salved  with  mercurial  ointment.  But  if  their  cause — the 
septic  state  of  the  ulcer — be  removed,  they  will  disappear  without  special 
treatment. 

(h)  Cutaneous  and  Subcutaneous  Phlegmon. — This  graver  form  of  sup- 
puration is  marked  by  violent  local  and  general  symptoms.  High  fever, 
with  rigors,  the  general  sense  of  sickness,  headache,  and  a  foul  tongue  and 
breath  are  present.  The  skin  over  the  focus  of  infection  becomes  deeply 
inflamed,  cedematous,  and  shows  dense  infiltration,  manifested  by  hardness 
and  pitting.  The  constant  gnawing  pain  puts  sleep  out  of  the  question, 
and  the  spreading  of  the  affection  over  new  areas  of  tissue  is  evident. 


186 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Cataplasm  or  Incision  ? 

The  question  whether  resolution  of  the  gathering  by  topical  applications, 
hot  or  cold,  should  be  attempted,  or  immediate  incision  should  be  resorted 
to,  is  of  great  practical  importance,  and  not  always  easy  to  determine. 

The  intensity  and  extent  of  the  process  should  he  herein  the  main  guide. 
The  consideration  that  an  incision  is  after  all  the  most  effective  antiphlo- 
gistic measure,  affording  relief  from  tension,  evacuating  a  very  large  pro- 
portion of  the  noxious  substances,  and  permitting  the  direct  application  of 
antiseptics — in  short,  that  it  promises  prompt  success,  conserves  a  large  part 
of  the  affected  tissues,  saves  much  pain  and  suffering,  and  averts  local  and 
general  danger — should  stand  foremost  in  the  surgeon's  mind,  whose  per- 
suasive authority  ought  to  gain  the  patient's  consent  to  an  early  operation. 
Especially  where  the  rapid  spread  of  the  affection  and  grave  general  symp- 
toms make  prompt  relief  urgent,  dilatory  measures  and  cowardly  tempor- 
izing are  imjDroper.  The  cataplasm  is  resorted  to  not  only  to  allay  the 
patienfs  pain  and  fear,  but  often  serves  as  a  convenient  mantle  to  hide 
ignorance  or  indecision. 

Carbuncle  represents  the  most  pronounced  form  of  cutaneous  phlegmon, 
and  its  treatment,  given  hereunder,  may,  with  due  modifications,  serve  as 
a  type  of  the  therapy  for  the  entire  class  of  cutaneous  suppurations. 

Out  of  motives  of  humanity,  and  because  it  offers  the  surgeon  time  and 
deliberation,  so  necessary  for  thorough  work,  ansesthesia  is  always  advisable, 
— in  many  cases  indispensable.  After  the  usual  preparations  for  an  anti- 
septic operation,  a  free  incision  should  be  made  through  the  middle  of  the 

inflamed  area,  penetrating  through  the 
skin  to  tlie  fascia.  One  or  more  small 
foci  filled  with  pus  will  be  thus  opened. 
If  their  number  be  great,  two  or  tliree 
more  parallel  incisions  should  be  added. 
The  engorgement  or  hard  infiltration  of 
the  adjacent  skin  will  be  admirably  re- 
moved by  VolJcmami's  multiple  punctur- 
ing (Fig.  141).  The  blade  of  a  narrow, 
straight  bistoury  or  tenotomy  knife  is 
grasped  about  one  third  of  an  inch  from 
its  point,  and  is  thrust  in  quick  succes- 
sion thirty,  forty,  or,  in  very  extensive 
cases,  a  hundred  times  through  different 
parts  of  the  infiltrated  region.  The 
punctures  should  be  evenly  distributed.  A  large  quantity  of  bloody  lymph, 
or  occasionally,  if  a  vein  be  hit,  pure  blood  will  escape,  and  the  swelling 
and  hardness  will  at  once  be  markedly  reduced.  No  attempt  should  be 
made  to  check  this  escape  of  blood  or  serum,  as  coagulation  will  soon  stop 
the  flow.  Thorough  irrigation  with  corrosive-sublimate  lotion,  packing  of 
the  deeper  incisions  with  strips  of  iodoformed  gauze,  and  an  ample  moist 


Fig.  141.— Attitude  <<(  liiinl  \\,r  multiple 
puncture.     (WilkMiaiiii.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  187 

dressinr/,  held  in  place  by  loose  turns  of  bandage,  will  comj)lete  the  work. 
An  immediate  fall  of  the  tem})eratnre,  with  marked  local  and  general  relief, 
will  reward  both  patient  and  surgeon.  Daily,  later  on,  a  rarer  change  of 
dressings  will  lead  to  a  rapid  cure. 

If  the  patient  declines  an  operation,  topical  applications  are  in  order. 
Cold,  in  the  shaj)e  of  iced  compresses,  or  the  ice-bag,  will  be  proper  where 
the  affection  is  superficial  and  accompanied  by  lymphangitis.  On  the  whole, 
it  may  be  said  that  cold  is  beneficial  in  the  initial  stages  of  most  phlegmon- 
ous affections,  and  is  often  very  well  borne  and  efficacious  in  the  milder 
forms.  To  many  it  becomes  unbearable  from  the  time  that  suppuration 
is  well  established,  and  often  induces  a  severe  chill,  the  real  cause  of  which, 
however,  is  always  to  be  sought  in  the  presence  of  pus. 

Note. — Cold  is  badly  borne  by  elderly  or  run-down  subjects,  or  those  prone  to 
rheumatism. 

Drt/  or  moist  heat  is  very  soothing  to  many  patients,  and  is  a  power- 
ful stimulant  to  the  local  circulation.  Occasionally  it  undoubtedly  averts 
threatening  suppuration,  and  may  aptly  be  employed  as  a  tentative  or  itiiti- 
atory  measure.  However,  if  the  local  and  general  symptoms  continue  to 
increase,  it  should  not  beguile  the  surgeon  into  procrastination.  Especially 
if  a  gathering  become  so  massive  as  to  cause  fluctuation,  incision  should  not 
be  further  delayed. 

Note. — The  main  effect  of  the  curious  and  often  incomprehensible  combinations  of  sub- 
stances entering,  at  the  recommendation  of  laymen  and  some  physicians,  into  the  composition  of 
poultices,  seems  to  be  upon  the  faith  and  imagination  of  the  patient.  Moist  heat  is  their  active 
property,  and,  the  simpler  and  cleaner  its  employment,  the  better  it  will  be.  The  nauseous  prac- 
tice of  smearing  the  skin,  or,  still  worse,  a  wound,  with  hot  linseed  dough,  is  not  yet  extinct. 
Even  a  well-inclosed  poultice  is  not  a  proper  covering  to  a  wound,  unless  a  clean  cloth  and  clean 
mush  be  taken  for  each  application.  Certainly  a  mixture  of  soured  linseed  with  ichor  and  pus, 
inclosed  in  a  foul  rag,  is  the  worst  of  all  abominations  that  a  decaying  era  of  surgery  has  left 
behind  as  its  legacy.  A  clean  cloth  dipped  in  and  wrung  out  of  hot  wafer,  covered  over  with  a 
piece  of  oiled  silk,  is  the  best,  the  cheapest,  and  the  least  unappetizing  of  all  cataplasms.  The 
cataplasm  should  never  be  placed  in  actual  contact  with  a  wound.  The  interposition  of  a  thin, 
moist  dressing  will  protect  the  wound  from  mechanical  insults  unavoidably  connected  with  the 
change  of  poultice,  and  the  poultice  itself  will  thus  remain  unsoiled  by  the  secretions  of  the 
wound. 

For  special  treatment  of  carbuncle,  see  page  210. 

Sulcutaneous  phlegmon,  left  to  itself,  or  treated  by  too  long  poul- 
ticing, will  assume  very  large  proportions.  The  form  of  the  abscess  cavity 
is  rarely  globular,  but  mostly  irregular  and  sinuous.  This  is  partly  due  to 
confluence  of  several  smaller  abscesses,  partly  to  irregular  extension,  caused 
by  the  varying  density  of  the  subcutaneous  connective  tissues.  Fluctuation 
soon  appears,  and  without  delay  one  or  more  incisions  should  be  placed  so 
as  to  drain  every  recess  in  the  most  direct  manner.  Volkmann's  punctua- 
tion of  the  peripherical  infiltration  of  the  skin,  a  thorough  irrigation  of  the 
caviiy,  and  a  moist  dressing,  constitute  the  treatment  of  these  cases.  The 
first  incision  is  made  where  fluctuation  is  most  marked;  the  index-finger  of 
the  left  hand  is  then  cautiously  inserted,  and  carefully  explores  the  interior 


188 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  the  abscess.  This  examination  is  very  important,  and  upon  its  result 
depends  the  locating  of  the  drainage-tubes.  Counter-incisions  are  made 
over  the  tip  of  the  left  index,  which  pushes  up  the  skin  from  within.  All 
squeezing  of  the  abscess  at  this  stage  of  the  operation  should  be  carefully 
avoided.  After  the  placing  of  the  drainage-tubes,  and  a  thorough  irriga- 
tion, no  pus  should  be  contained  in  the  abscess.  If,  therefore,  gentle 
external  j^ressure  causes  the  escape  of  new  masses  of  pus,  this  is  a  sign  that 
one  or  more  recesses,  communicating  by  small  openings  with  the  main  cavity, 
remain  U7idrained,  and  need  further  attention.  They  must  be  located,  and 
separately  incised  and  drained. 

If  fluctuation  persist  over  one  or  more  places  in  the  vicinity  of  the  cen- 
tral abscess,  it  will  be  found  that  unopened,  independent  abscesses  require 

additional  incisions. 
Fig.  i42.-Hmon-E^er^s  method  of  incising  a  rj^j^g  ^^^^^^  tearing  and  break- 

ing down  of  septa  of  tissue  with- 
in the  abscess  by  the  surgeon's 
finger  is  unsafe,  on  account  of 
the  unnecessary  haemorrhage  it 
provokes,  and  because  it  may 
lead  to  pulmonary  embolism.  It 
is  better  to  make  a  sufficient 
number  of  counter-incisions. 

The  squeezing  out  of  abscess- 
es through  an  insufficient  sjDon- 
taneous  or  artificial  ojoening  con- 
stitutes what  may  be  called  sur- 
gical barbarism.  If  the  opening 
is  too  small  or  improperly  placed, 
the  abscess  can  never  be  drained 
by  the  aid  of  the  law  of  gravity 
alone.  External  pressure  must 
be  employed  to  remove  its  con- 
tents, and  this  must  be  often 
repeated  to  prevent  refilling  of 
the  abscess.  As  "squeezing  out" 
is  a  very  painful  process,  the  pa- 
tient will  naturally  shrink  from 
it,  and  will  let  matters  go.  The 
abscess  becoming  nearly  filled, 
only  the  overflow  will  escajie 
til  rough  the  insufficient  aper- 
ture. The  result  is  slow  exten- 
sion of  the  suppurative  process, 
with  continuous  fever.  Dressings  of  any  kind  will  only  make  matters  worse, 
and  no  relief  will  follow  till  another  more  ])roperly  located  artificial  or  spon- 
taneous opening  supply  the  defect  of  drainage. 


Pio.  143.— Completed  dressinfi  of  cervical  abscess. 


DIAGNOSIS  AND  TKEx^TMENT  OF  PHLEGMON. 


189 


Fig.  144. 


-Underpadding  of  safety-pins  thrust  tliroutcli  drainage- 
tubes  after  incision  of  ceiVtcal  abscess. 


The  best  proof  of  the  adequate  treatment  of  an  abscess  is  the  fact  that 
at  change  of  dressings  the  cavity  is  found  emjjty,  and  all  the  secretions  are 
contained    in    the 
dressings. 

The  frequency 
of  the  change  of 
dressings  should  be 
regulated  by  the 
amount  of  the  dis- 
charge. 

{c)  Deep  -  seat- 
ed or  Subfascial 
Phlegmon.  Lymph- 
Gland  Abscess.  — 
Still  more  serious 
than  subcutaneous 
suppuration  is  a 
phlegmonous  in- 
flammation of  the  superficial  or  deep-seated  lymphatic  glands,  or  the  sub- 
maxillary or  the  parotid  salivary  glands.  The  danger  of  these  forms  of 
septic  tissue-decomposition  consists  in  the  great  tension  which  their  pois- 
onous contents  attain  ;  the  difficulty  of  their  spontaneous  evacuation  on 
account  of  the  massive  barriers  interposed  between  them  and  the  surface  of 
the  body,  and  last,  but  not  least,  the  likelihood  of  their  perforation  into  the 
mediastinum,  pleura,  or  peritonaeum,  or  the  erosion  of  large  vessels  situated 
in  their  immediate  vicinity. 

Deep-seated  phlegmon  is  characterized  by  the  extremely  hard  and  deep- 
going  infiltration  of  the  superjacent  tissues,  a  general  and  massive  oedema 
of  the  soft  parts,  extending  far  beyond  the  limits  of  the  inflammatory  pro- 
cess, so  that  a  limb,  for  instance,  attains  double  its  size  ;  marked  functional 
disability  of  all  organs,  even  distantly  related  to  the  focus  of  disturbance, 
and  very  violent  symptoms  of  systemic  septic  poisoning. 

In  the  beginning  the  skin  covering  the  affected  locality  is  oedematous 
but  pale  ;  gradually  it  flushes  up  and  becomes  hard  and  brawny. 

Incision  and  drainage  is  the  sovereign  therapy  in  these  cases.  N^o  time 
should  be  wasted  in  attempts  at  an  abortive  treatment,  as  every  hour  of 
delay  may  cause  irreparable  damage.  The  distant  hope  of  resolution,  or 
the  desire  to  produce  ''maturing"  by  poulticing,  should  not  be  allowed  any 
weight  in  the  face  of  the  knowledge  that  extensive  necrosis  is  the  unavoida- 
ble consequence  of  the  rapidly  increasing  dense  infiltration  characteristic  of 
this  condition.  Relief  from  excessive  tension  is  the  first  and  most  urgent 
indication,  and  this  can  be  done  only  by  an  incision. 

The  objection  that  these  abscesses  can  not  be  opened  safely  while  they 
are  small,  is  erroneous,  as  will  be  shown  directly.     But,  even  if  the  surgeon 
should  not  succeed  in  opening  the  small  cavity,  cutting  through  the  integu- 
ment and  fascia  will  do  material  service  by  averting  the  greatest  danger. 
2r. 


190  RCTLES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

HiUon-Roser's  method  offers  a  safe  and  easy  manner  of  evacuating  these 
foci.  Anfestliesia  is,  of  course,  indispensable.  A  free  incision  through  the 
skin  over  the  most  prominent  part  of  the  swelling  should  expose  the  fascia, 
which  should  also  be  divided  by  easy  strokes  of  the  point  of  the  knife  to  a 
sufficient  extent,  say  an  inch  or  two.  After  this  the  knife  is  laid  aside.  If 
a  small  aspirator  be  at  hand,  search  for  pus  can  be  made  by  puncturing  and 
aspirating  different  parts  of  the  swelling.  This,  however,  is  not  necessary. 
A  grooved  director  is  inserted  into  the  center  of  the  incision,  and  is  briskly 
thrust  into  the  swelling,  or,  if  large  vessels  be  near,  is  gradually  insinuated 
by  steady  rotating  pressure.  At  a  certain  point  resistance  will  suddenly 
cease,  and  a  drop  of  ichor  or  pus  will  be  seen  exuding  from  the  groove  of 
the  instrument.  A  dressing-forceps  should  now  be  placed  in  the  groove 
of  the  director,  and  should  be  pushed  into  the  focus.  The  grooved  director 
can  now  be  removed,  and  the  forceps  withdrawn  while  its  branches  are  held 
as  wide  open  as  possible.  A  gush  of  bloody  pus  will  follow  the  instrument. 
If  the  opening  be  too  small,  dilatation  with  the  dressing-forceps  should  be 
repeated  once  or  twice,  until  it  becomes  large  enough  to  admit  a  stout  drain- 
age-tube. Irrigation  and  a  moist  dressing  complete  the  procedure.  (Figs. 
142,  143,  and  144). 

If  the  incision  was  delayed  too  long,  the  relief  of  the  general  symptoms 
will  not  be  as  prompt  as  after  early  operations.  The  presence  of  adherent 
necrotic  tissues  explains  this  fact.  But  the  spread  of  the  mortification  is 
checked,  and  the  fever  will  abate  as  soon  as  the  sloughs  become  detached 
and  expelled. 

Very  numerous  applications  have  taught  the  author  the  great  value  and 
safety  of  this  method,  which,  therefore,  can  be  warmly  recommended. 

Fluctuation  is  a  very  late  symptom  in  all  deep-seated  abscesses,  and 
should  not  be  waited  for.  An  explorative  aspiration  of  a  doubtful  swelling 
will  generally  disperse  uncertainty,  and  the  production  of  pus  will  induce 
the  patient  to  consent  to  the  incision. 

The  haemorrhage  from  large,  deep-seated  abscesses  is  sometimes  copious. 
It  comes  from  the  walls  of  the  abscess  cavity,  which  are  very  vulnerable  ; 
hence  rough  exploration,  squeezing,  or  any  unnecessary  manipulations 
should  be  carefully  avoided. 

Note. — It  is  best  in  cases  of  great  emaciation  to  open  the  abscess  according  to  Hilton-Roser 
— to  insert  a  large-sized  tube,  and  to  desist  altogether  from  exploration  and  irrigation  until  a 
few  days  later.  The  cavity  will  contract,  its  contents  will  spontaneously  escape  toward  the  point 
of  least  resistance — that  is,  through  the  drainage-tube— to  be  absorbed  by  the  dressings,  and 
much  blood  will  be  saved  in  this  manner. 

Phlegmonous  Erysipelas. — A  combination  of  extensive  phlegmon  with 
true  erysipelas  is  not  very  common.  What  is  ordinarily  known  as  "phleg- 
monous erysipelas"  is  generally  nothing  but  a  very  extensive  subcutaneous 
phlegmon,  mostly  with,  sometimes  without,  subfascial  complications.  The 
worst  cases  are  directly  chargeable  to  prolonged  poulticing,  and  their  treat- 
ment is  rendered  very  difficult  by  the  frequent  occlusion  of  the  drainage- 
tubes  by  large  tow-like  masses  of  necrosed  connective  tissue  and  fascia. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


191 


Fig.  145. 


-Bacilli  of  malignant  a?dema  or  acute  progressive 
phlegmon  (700  diameters).     (Koch.) 


Gcmfircnoux  phlcfimon  (Pirogoff's  ticute  purulent  oedema)  represents  one 
of  the  liigliost  degrees  of  microbial  ])oisoning,  where  the  multiplication  of 
the  micro-organisms  is 
so  rapid  and  pervad- 
ing that  the  establish- 
ment of  innumerable 
foci  throughout  all  of 
the  tissues  composing  a 
Avhole  limb  leads  to  ex- 
tensive general  infiltra- 
tion. Board-like  hard- 
ness, a  dusky  hue  of  the 
integument,  blebs  and 
ecchymoses,  and  finally, 
thrombosis  of  veins  and  arteries,  will  end  in  necrosis  of  the  entire  enor- 
mously swollen  and  cold  limb.  Incisions  do  not  yield  pus,  but  only  give 
vent  to  scanty  quantities  of  turbid  ichorous  serum.      In  these  cases  the 

prognosis  is  very  bad,  and 
the  most  heroic  incisions 
rarely  succeed  in  saving 
the  member.  If  too  long 
delayed,  even  a  high  am- 
putation may  fail  to  save 
the  patient's  life.  (Figs. 
145  and  146.) 

Em/phyfiematous  Ga n- 
grene. — The  inoculation 
of  the  human  organism 
with  a  specific  bacterium 
(Fig.  134)  is  generally  followed  by  the  development  of  a  dusky,  rapidly 
spreading  infiltration,  exhibiting  on  palpation  the  peculiar  crackling,  and 
on  percussion,  the  tympanitic  sound  of  subcutaneous  emphysema.  The 
process  is  accompanied  by  profound  septic  intoxication,  with  delirium,  high 
temperatures,  chills,  and  dejection,  and  terminates  in  gangrene  of  the 
affected  parts.  Eesolute  measures— that  is,  timely  amputation  performed 
through  healthy  parts — may  succeed  in  preventing  a  fatal  issue. 

{d)  Acute  Infectious  Osteomyelitis.— Suppuration  of  the  medullary  sub- 
stance of  parts  of  the  skeleton  represents  one  of  the  most  dangerous  and 
destructive  forms  of  phlegmon.  Its  cause  is  the  establishment  of  cult- 
ures of  the  gold- colored  grape-coccuf<  in  the  capillaries  or  arterioles  of  the 
marrow.  The  manner  in  which  this  infection  occurs  is  still  matter  of 
controversy.  So  much,  however,  is  known  that  it  is  most  common  during 
adolescence,  and  that  a  preceding  suppuration,  followed  by  exposure  to 
weather,  or  certain  traumatisms,  are  common  provocative  causes. 

The  invasion  is  marked  by  a  severe  chill,  followed  by  a  deep  alteration 
of  the  general  well-being.    Very  high  temperatures,  with  chills,  somnolency. 


Fig, 


141). — -Bacilli  of  malisfnant  oedema  in  the  kidney 
(TOO  diameters).     (Koch.) 


192  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

a  dry  tongue,  foul  bretith,  intense  gastric  disturbance,  bear  witness  to  the 
gravity  of  the  disorder.  The  insidiousness  of  the  local  and  the  gravity  of 
the  general  symptoms  lead  to  frequent  errors  of  diagnosis  on  the  part  of 
practitioners  who  never  have  seen  this  affection,  or  are  careless  observers. 
The  favorite  locality  of  the  disease  is  the  shaft  of  the  long  bones  near  one 
or  another  epiphysis,  as,  for  instance,  the  lower  end  of  the  femur.  This, 
together  with  the  upper  part  of  the  shaft  of  the  tibia,  is  its  classical  seat. 
No  bone,  however,  is  exempt  from  the  disorder. 

The  first  local  manifestation  is  a  deep-seated,  unbearable  pain,  soon  fol- 
lowed by  a  general  and  deep-going  oedema  of  all  the  soft  parts  overlying  the 
focus.  The  skin  is  pale.  As  the  soft  parts  covering  the  adjacent  joint  are 
also  swollen,  and  its  movement  is  painful,  the  erroneous  diagnosis  of  acute 
articular  rheumatism  is  frequently  made. 

Often  the  patient  is  unconscious  or  quite  listless  at  the  time  of  the  phy- 
sician's first  visit,  and  the  local  symptoms  escape  attention.  As  a  matter 
of  fact,  typhoid  fever  or  meningitis  is  frequently  diagnosticated,  and  the 
affection  remains  unrecognized  until  the  appearance  of  a  fluctuating  swell- 
ing or,  in  extreme  cases,  spontaneous  perforation  of  an  abscess  dispel  the 
error. 

The  essential  features  of  the  morbid  process  are  identical  with  those  of 
cellular  phlegmon,  modified,  however,  by  the  peculiar  structure  of  bone. 
On  account  of  the  rigidity  of  the  osseous  lamellae  inclosing  the  Haversian 
canals  ;  of  the  cancellous  and  cortical  substances  inclosing  the  medullary 
tissue,  and  of  the  periosteum,  the  dense  infiltration  and  massive  exudation 
will  rapidly  heighten  the  intraosseous  tension  to  such  a  degree  that,  the  ves- 
sels becoming  occluded,  more  or  less  extensive  necrosis  results. 

The  excessive  tension  of  the  noxious  exudations  penned  up  within  the 
rigid  tissues  will  cause  a  copious  overflow  and  absorption  of  plasm  charged 
with  ptomaines,  which  will  not  fail  to  cause  a  profound  intoxication,  mani- 
fested by  very  grave  general  symptoms. 

Cortical  osteomyelitis,  or  what  is  known  in  text-books  as  suippurative 
periostitis,  is  the  mildest  form  of  the  affection,  and  is  most  amenable  to 
preventive  treatment.  The  necrosis  caused  by  it  generally  involves  the 
outer  part  of  the  bone  only,  producing  a  cortical  sequestrum.  When  the 
epiphysis  is  attacked  in  the  vicinity  of  a  joint,  perforation  and  articular 
suppuration  may  occur  and  very  seriously  complicate  the  case. 

Case. — S.  C,  aged  twelve,  a  somewhat  anaemic  boy,  received,  December  19,  1882, 
a  kick  from  a  playmate  upon  the  spine  of  the  tibia,  which  caused  considerable  pain  for 
a  while,  but  no  discoloration.  The  next  day  a  severe  chill,  with  intense  local  pain 
and  an  extensive  hard  swelling  of  the  injured  region,  set  in.  The  boy  became  listless 
and  delirious ;  he  rapidly  emaciated ;  the  swelling  extended  in  all  directions.  The  author 
saw  the  patient  December  29,  1882,  in  consultation  with  the  family  attendant,  who, 
two  days  previous  to  this  meeting,  had  made  a  small  incision  corresponding  to  one  of 
the  many  points  where  perforation  of  the  skin  threatened.  The  boy  being  anaesthe- 
tized, a  free  incision  three  inches  in  length  was  made  by  gradual  preparation  down  upon 
the  anterior  surface  of  the  tibia,  beginning  a  little  below  the  jjatella.     Every  bleeding 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  193 

vessel  was  carefully  tied  at  once,  and  thus  clear  insight  and  much  bloodsaving  were 
effected.  A  large  ulcerative  defect  of  the  periosteum  was  found  corresponding  to  a 
well-circumscribed  greenish-yellow  spot  of  tlie  tibia.  This  defect  extended  to  the  caj)- 
sule  and  into  the  knee-joint,  which  was  found  in  open  communication  with  the  sub- 
periosteal abscess,  and  was  distended  with  pus.  Two  incisions  were  made  into  the 
joint  for  purposes  of  drainage.  The  popliteal  space,  thigh,  and  calf  contained  a  num- 
ber of  burrowing  secondary  abscesses,  mostly  subcutaneous,  which  were  also  severally 
incised  and  drained.  The  entire  major  saphenous  vein  was  found  in  a  state  of  puru- 
lent phlebitis,  its  course  being  marked  by  a  chain  of  small,  angry-looking  swellings  of 
the  skin,  which,  on  being  opened,  all  yielded  pus.  As  it  was  probable  that  the  entire 
vein  would  suppurate,  it  was  slit  up,  beginning  from  the  ankle,  to  within  a  few  inches 
of  Poupart's  ligament,  and  the  remaining  parts  of  the  thrombus  were  turned  out.  The 
lisemorrhage  from  entering  branches  was  checked  by  packing  with  narrow  strips  of 
iodoformed  gauze.  A  very  tardy  improvement  followed  these  extensive  measures. 
January  10,  1883. — A  third  incision  into  the  upper  recess  of  the  knee-joint,  and  two 
more  counter-incisions  were  made  into  the  popliteal  space.  Large  masses  of  necrosed 
connective  tissue  came  away  at  almost  each  change  of  dressings,  and,  althougli  the 
febrile  disturbance  had  muchi  abated,  the  boy  seemed  to  steadily  lose  ground  on  account 
of  the  enormous  suppuration.  The  cleansing  of  the  wounds  was  so  slow,  the  pain-  and 
suffering  at  the  unavoidably  frequent  change  of  dressings  so  distressing  and  enervating 
to  the  patient,  that,  January  14th,  amputation  was  thought  of  as  a  last  resort.  The 
parents,  however,  firmly  declined  the  step,  and  fortunately  so,  as  the  boy  ultimately 
recovered,  with  anchylosis  of  the  knee-joint.  A  few  small  shells  of  necrosed  bone  came 
away  from  the  epiphysis  previous  to  the  definitive  closure  of  the  wound. 

Central  osteomyelitis  is  much  more  destructive  to  the  osseous  tissue  than 
the  cortical  affection,  often  causing  necrosis  of  the  entire  shaft.  It  fre- 
quently extends  to  the  epiphysis,  and  involves  the  adjacent  joint. 

Note. — The  excruciating  pain  felt  by  the  patient  is  principally  due  to  the  tension  of  the 
periosteum,  separated  from  the  bone  by  more  or  less  pus.  Ordinarily,  the  extension  of  suppura- 
tion by  perforation  into  healthy  parts  is  marked  by  an  increase  of  the  local  and  general  suffer- 
ing. Not  so  in  osteomyelitis.  Perforation  of  the  periosteum,  and  evacuation  into  a  loose  plane 
of  connective  tissue,  is  always  marked  here  by  relief  of  the  intense  periosteal  pain,  and  often  by 
a  temporary  decline  of  the  fever,  due  to  the  reduction  of  the  enormous  tension  which  first  pre- 
vailed. With  the  increase  of  the  tension  in  the  secondary  abscess  the  fever  rises  again,  but  the 
pain  never  reaches  its  former  intensity. 

Similar  relations  obtain  in  all  forms  of  suppuration  where  the  seat  of  the  morbid  process  is 
confined  by  dense  fascia  or  the  capsule  of  a  joint.  Submaxillary  and  parotid  cynanche,  septic 
inflammations  within  the  prepatellar  or  olecranic  bursse,  and  all  joint-suppurations  exhibit  the 
same  peculiarity.  As  long  as  the  suppurative  process  is  confined  within  the  mentioned  closed 
spaces,  the  tension  and  its  immediate  consequences — necrosis  and  copious  overflow  of  fever-gen- 
erating poisonous  material  into  the  lymphatics,  causing  intense  toxic  symptoms — are  at  their 
acme.  As  soon  as  perforation  and  partial  evacuation  of  incarcerated  pus  into  the  meshes  of  the 
vicinal  loose  connective  tissue  occurs,  a  relaxation  of  the  intense  pain  and  a  temporary  remis- 
sion of  the  septic  fever  are  observed. 

Can  Necrosis  he  averted  ? — Where  the  diagnosis  is  made  out  early,  where 
the  superficial  situation  of  the  bone — for  instance,  the  tibia — favors  a  precise 
localization  of  the  focus,  and  where  the  affection  is  cortical,  a  free  and  early 
incision  may  avert,  and,  as  a  matter  of  fact,  often  does  avert,  necrosis,  or  at 
least  will  prevent  its  extension.  In  the  beginning,  perhaps,  even  the  ravages 
of  central  osteomyelitis  could  be  limited  by  early  trepanning  of  the  medul- 


194  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGEEY. 

lary  space  in  one  or  more  places.  So  much  is  certain  and  proved  by  experi- 
ence, that  prompt  incision  of  the  periosteum  and  trepanning  of  the  affected 
bone  admirably  relieves  the  acuity  of  the  local  and  general  symptoms. 

Case. — The  author  has  to  quote  from  memory  a  very  instructive  case  of  recent 
infectious  osteomyelitis  of  tlie  lower  end  of  the  humerus  observed  in  1880  in  the  surgi- 
cal department  of  the  German  Dispensary,  and  operated  in  the  presence  of  Dr.  W. 
Bnlser  and  other  colleagues.  A  young  woman,  exhibiting  an  unusual  degree  of  lassi- 
tude and  a  pitiable  facial  expression  of  suffering,  was  led  into  the  place  by  two  of  her 
friends.  Her  left  elbow -joint  was  semiflexed;  it  showed  a  pale,  dense,  and  uniform 
swelling.  Her  attendants  reported  that  she  had  had  a  severe  chill  in  the  morning  of 
the  preceding  day,  and  had  been  very  sick  ever  since  then.  The  thermometer  showed 
105°  Fahr.  in  the  axilla.  Extremely  acute  pain  was  complained  of  in  the  lower  end 
of  the  humerus,  just  above  the  olecranon.  Osteomyelitis  being  diagnosed,  the  patient 
was  angestbetized.  A  good-sized  hollow  needle  being  inserted  until  its  point  was  caught 
by  the  bone  at  the  site  mentioned,  a  drop  or  two  of  thick  pus  appeared  in  the  barrel 
of  the  hypodermic  syringe.  An  ample  incision  was  carried  along  the  outside  of  the 
triceps  tendon  down  to  the  bone,  whereupon  about  two  drachms  of  pus  escaped.  The 
periosteum  was  found  detached,  and,  being  deflected  by  an  elevator,  was  found  turgid 
and  deep  red,  except  at  the  place  of  detachment,  where  it  was  broken  down  and  green- 
ish-yellow. Profuse  oozing  took  place  from  the  exposed  bone  and  periosteum,  except- 
ing an  irregular  area  of  bone  covering  about  two  square  inches  just  above  the  posterior 
supratrochlear  fossa.  This  area  was  grayish  yellow,  and  did  not  bleed— in  short,  was 
necrosed.  The  wound  was  loosely  packed  with  carbolized  gauze,  and  was  enveloped 
in  a  moist  dressing.  The  patient  was  taken  to  her  home,  whence  she  was  removed  the 
following  day  to  a  hospital  by  her  relatives,  because  she  was  too  sick  to  be  taken  care 
of  at  home.  The  author  was  assured  that  her  mcessant  moaning  due  to  the  excruciat- 
ing pain  had  stopped  during  the  night  following  the  operation. 

Some  years  ago  the  author  saw  a  fatal  case  of  pelvic  osteomyelitis  in  consultation 
with  Dr.  H.  Kudlich.  The  patient  succumbed  to  the  violence  of  the  initial  symptoms 
— that  is,  to  acute  septicaemia.  The  seat  of  the  disease  was  the  sacrum  and  os  ilium  of 
a  very  muscular  man.  Very  intense  sciatica  and  high  fever  composed  the  initial  symp- 
toms. Enormous  oedema  of  the  left,  thigh  and  inguinal  region  appeared  a  short  time 
before  death,  revealing  the  nature  of  tbe  affection,  which  until  then  bad  baffled  attempts 
at  diagnosis.  The  pelvis  was  found  occupied  by  phlegmon  extending  below  Poupart's 
ligament.  The  probable  source  of  the  infection  was  a  recrudescent  suppurative  otitis 
media  of  old  standing. 

The  subject  is  full  of  difficulty  and  surrounded  by  many  drawbacks  in 
all  its  aspects.  The  impossibility  of  an  early  and  precise  diagnosis  as  to 
location,  the  depth,  and  often  the  inaccessibility  of  the  seat  of  the  disease, 
will  render  many  cases  impracticable  for  preventive  treatment. 

Secondary  abscesses  must  be  incised  and  drained  as  early  as  possible 
according  to  rules  above  given. 

(e)  Chronic  Suppuration  due  to  Bone  Necrosis.  Necrotomy. — The  most 
common  seats  of  acute  osteomyelitis  and  subsequent  bone  necrosis  are  thie 
femur  and  tibia  near  the  knee-joint. 

This  fact  may  perhaps  be  explained  by  the  circumstance  that  the  upper 
epiphysis  of  the  tibia  and  the  lower  epi])hysis  of  the  femur  ossify  much 
later  than   the  other  epiphyses  of  tliese  bones.      Tlic  active  growtli  and 


DIAGNOSIS  AND  TREATMENT   OF  PHLEGMON. 


195 


Fig.  147.- 


-Necrotomy  of  tibia.     Leg  placed  on  a  hard  cushion.     Irrigator 
playing  Irbm  the  right. 


abundant  blood-,>^upi)ly  near  the  knee-joint  seem  to  favor  the  importation 
and  deposition  there  of  active  micrococci  circulating  with  the  blood. 

Next  in  frequency  of  be- 
ing attacked  is  the  lower  jaw 
near  the  angle,  and  the  upper 
end  of  the  shaft  of  the  hu- 

^OTE. — Very  likely  the  different 
gement  of  the  nuti'ient  vessels 
bones  of  the  upper  and  lower 
eniities  has  a  certain  influence  up- 
on the  frequency 
of  the  location  of 
osteomyelitis  near 
the  knee  and  shoul- 
der joints.  The 
nutrient  vessels  of 
the  femur  and  tibia 
diverge  from,  the 
knee  -joint ;  those 
of  the  humertis  and 
the  hones  of  the 
forearm  converge 
toward  the  elbow* 
The  direct  and 
abundant  blood-supply  of  the  malleoli  and  the  coxal  end  of  the  femur  seems  to  cause  an 
earlier  consummation  of  the  osteogenetic  process  at  these  localities,  and  also  makes  them 
liable  to  a  form  of  infection  peculiar  to  the  infantile  period  of  life — namely,  tuberculosis. 
Tubercular  affections  of  the  ankle-  and  hip-joints  are  more  common  in  children  than  white  swell- 
ing of  the  knee.  During  adolescence,  when  the  physiological  fluxion  toward  the  knee-joint  pre- 
ponderates over  that  toward  the  ankle  and  hip,  the  tendency  to  osteomyelitis  near  and  tubercu- 
losis near  and  in  the  knee-joint  becomes  more  pronounced.  Similar  relations  seem  to  prevail  in 
reference  to  the  upper  extremity.  During  infancy  white  swelling  of  the  elbow  is  more  common 
than  that  of  the  shoulder  and  wrist-joints ;  in  adolescence  the  upper  end  of  the  humerus  is  the 
common  seat  of  acute  osteomyelitis ;  in  adults  the  shoulder  and  wrist  are  more  frequently 
attacked  by  tuberculosis  and  osteomyelitis. 

Whenever  an  attack  of  osteomyelitis  terminates  in  the  formation  of  an 
abscess  and  the  establishment  of  one  or  more  fistulae,  the  acute  features  of 
the  initial  stages  of  the  disorder  disappear.  The  abundant  discharge  of  pus 
is  followed  for  a  while  by  a  gradual  decrease  of  secretion,  which  again  in- 
creases as  the  separation  of  the  sequestrum  becomes  more  and  more  com- 
plete. This  is  explained  by  the  fact  that,  as  the  dead  bone  becomes  gradu- 
ally detached,  the  pus-generating  surface  of  the  cavity  containing  the 
sequestrum  becomes  proportionately  larger.  In  the  mean  time  new  osseous 
substance  is  thrown  out  by  those  portions  of  the  adjacent  bone  and  peri- 
osteum which  were  not  destroyed  by  suppuration,  and  thus  a  more  or  less 
perfect  involucrum  is  formed  around  the  sequestrum.  After  complete  de- 
tachment of  the  sequestrum,  suppuration  is  generally  profuse. 


*Hyrtl,  "Descriptive  Anatomie,"  ISYO,  p.  209. 


196 


RULES   OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


Fig.  148. — Diagram  of  a  transverse  section, 
showing:  relations  of  sequestrum,  involu- 
erum,  fistula,  and  skin. 


If  the  affection  is  extensive  and  no  spontaneous  or  artificial  relief  is 
vonchsafed  for  a  long  period,  a  deep  deterioration  of  the  general  health  will 

follow,  characterized  by  emaciation, 

Fi  <r  r.y/  n  ;  ... 

anaemia,  albuminuria,  and  in  extreme 
cases  by  amyloid  degeneration  of  the 
liver  and  kidneys. 

The  diagnosis  of  the  presence  of 
a  sequestrum  can  be  made  by  noting 
the  diffuse  thickening  of  the  affected 
bone,  the  profuse  secretion  from  one 
or  more  fistnlae,  and  by  direct  prob- 
ing. If  the  direction  of  the  sinuses 
be  straight,  the  silver  probe  will  strike 
bare  and  roughened  bone-surface.  The  latter  symptom,  however  desirable 
for  the  establishment  of  a  positive  diagnosis,  is  not  absolutely  necessary  to 
it.  Indeed,  the  cases  are  quite 
common  where  tortuous  chan- 
nels prevent  direct  probing. 

Detachment  of  the  seques- 
trum is  indicated  by  its  mo- 
bility under  the  pressure  of  the 
probe-j)oint,  or,  when  probing 
is  impracticable,  by  the  long 
duration  of  the  trouble  and 
the  increasing  or  profuse  dis- 
charge. 

WJien  to  Operate. — It  may 
be  laid  down  as  a  general  rule 
that  the  best  time  to  perform  sequestrotomy  is  after  complete  detachment 
of  the  dead  bone,  which  can  be  ascertained  either  by  probing  or  by  the 
general  aspects  of  the  case.     Eecognition  of  the  necrosed  parts  and  their 

complete  removal 
are  then  easy,  and 
will  be  followed  by 
a  rapid  cure.  This 
rule,  however,  ad- 
mits of  important 
exceptions. 

Note.  —  Extensive 
necroses  of  the  lower 
jaw  arc  frequently  ac- 
companied by  a  profuse 
discharge  of  fetid  pus 
into  the  oral  cavity. 
This  and  the  inability 
to  masticate  food,  do  Irequeutly  render  early  relief  by  operation  very  desirable.  The  objection 
that  to  perform  a  complete  operation  will  necessitate  the  sacrifice  of  healthy  bone  is  not  tenable, 


Fig.  149. — Neuber's  method.  Top  of  involucrum  re- 
moved, skin-flaps  turned  into  the  bottom  of  the 
bone-cavity. 


Fig.  150. — Schede's  method.     Diagram  showing 
van"  blood-clot. 


relation.s  of  organ- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  107 

as  it  may  be  urged  that  even  an  incomplete  operation,  if  it  only  accomplish  the  removal  of  the 
greatest  portion  of  the  sequestrum,  will  be  followed  by  a  decided  improvement  of  the  patient's 
condition.  After  a  while,  a  secondary  operation  can  be  done  under  more  favorable  circumstances. 
Similar  considerations  may  also  indicate  an  early  sequestrotomy  in  other  regions. 

Neckotomy. —  Artificial  unajinia  by  Esmarch's  band  and  antisepsis  have 
marked  important  changes  in  the  technique  of  sequestrotomy.  Control  of 
the  haemorrhage,  and  the  possibility  of  healing  even  the  largest  sequestrot- 
omy wounds  without  suppuration.  Justify  a  deliberate  search  after  detached 
foci  containing  sequestra  by  thorough  exposure  of  the  interior  of  the 
affected  bones.  Lo7ig  incisions  and  a  free  use  of  mallet  and  chisel  are 
proper.  A  compressive  antiseptic  dressing  will  insure  against  secondary 
hcBmorrliage.  The  formation  and  maintenance  of  a  moist  blood-clot  in  the 
wound  will  bring  about  rapid  filling  up  of  the  cavity  by  new-formed  bone, 
and  will  terminate  in  firm  and  speedy  cicatrization. 

The  introduction  of  the  use  of  Esmarch's  band  has  deprived  extensive 
necrotomies  of  their  chief  danger — profuse  haemorrhage.  The  danger  of 
septic  disturbances  following  necrotomy  was  slight  even  before  the  adoption 
of  the  antiseptic  method,  as  the  densely  infiltrated  state  of  the  adjoining 
tissues  made  absorption  of  septic  matter  from  the  wound  difficult,  and  their 
rigidity  rendered  efficient  drainage  very  easy.  The  chief  advantage  of  the 
antiseptic  method  is  to  be  sought  in  the  possibility  of  effecting  a  cure  with- 
out the  long  course  of  suppuration  formerly  characteristic  of  the  healing  of 
these  cases. 

Neuber's  implantation  of  skin-flaps  was  the  first  stop  in  the  direction  of 
accelerating  the  cure  of  necrotomy  wounds.  But  Schede^s  methodical  and 
successful  utilization  of  the  protective  properties  of  the  moist  blood-clot  is 
the  simplest  and  most  perfect  means  to  the  end  in  view. 

The  indispensable  conditions  for  a  successful  employment  of  Schede's 
method  are  laid  down  in  the  following  propositions  : 

First.  Thorough  exposure  of  the  seat  of  the  disease  by  incision  and  by 
the  use  of  mallet  and  chisel. 

Secondly.  Complete  removal  of  the  ivhole  sequestrum,  or  all  the  seques- 
tra, and  of  the  entire  jjyogenic  membrane  lining  the  cavities  and  sinuses, 
by  scooping  and  scraping  with  the  sharp  spoon. 

Thirdly.  Thorough  disinfection  of  all  the  nooks  and  crevices  of  the 
wound  by  a  vigorous  use  of  the  irrigator  and  corrosive-sublimate  lotion, 
and  by  wiping  it  out  with  a  clean  sponge. 

Note. — The  final  flushing  and  mopping  out  should  always  be  done  with  the  strongest  solution 
of  corrosive  sublimate  used  by  surgeons  (1 :  500).  Residua  of  this  strong  lotion  are  then  washed 
away  by  a  mild  solution  to  prevent  mercurial  poisoning. 

Fourthly.  The  formation  of  a  blood-clot  which  should  fill  up  the  wound 
to  the  level  of  the  skin,  and  its  preservation  from  putrefaction  and  exsicca- 
tion by  a  suitable  antiseptic  dressing  (page  10). 

Note. — Leaving  behind  the  smallest  spiculum  of  undetected  dead  bone,  or  a  shred  of  the 
pyogenic  membrane,  will  partially  or  totally  compromise  the  success  of  this  procedure,  and  no 
amount  of  irrigation  will  avert  suppuration.    Fulfillment  of  the  second  proposition  is  not  difficult 

27 


198  RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

except  in  the  disseminated  form  of  necrosis,  where  a  number  of  small  foci,  each  containing  its 
sequestrum,  and  all  connected  by  more  or  less  narrow  and  tortuous  channels,  are  scattered  within 
a  wide  area  of  the  affected  bone.  But  even  these  difficulties  can  be  overcome  by  the  exercise  of 
circumspection  and  painstaking,  favored  by  artificial  anaBmia,  which  renders  detection  of  dis- 
colored bone  and  the  entrance  to  bone  sinuses  comparatively  easy. 

WJiaf  CJ/isels  to  ttse. — The  chisels  generally  sold  by  surgical  cutlers  have 
little  to  commend  them  for  efficient  and  rapid  work.  Their  shape  and  size 
are  unsuitable.  ''Albert  Buck's  warranted  chisels,"  as  sold  by  most  hard- 
ware dealers,  and  generally  used  by  carpenters  and  joiners,  are  well  tem- 
pered and  excellent.  They  should  be  fastened  to  an  ordinary,  smooth, 
wooden  handle,  without  indentations,  to  insure  the  possibility  of  perfect 
cleansing.  The  author  has  found  a  set  consisting  of  a  one-inch,  a  half- 
inch,  and  a  third-inch  chisel,  and  of  a  one-inch  and  a  half-inch  gouge,  to 
answer  every  purpose,  A  light  wooden  mallet,  perfectly  smooth,  its  head 
made  of  boxwood,  can  be  bought  in  any  house-furnishing  establishment,  and 
is  much  pi-eferable  to  the  small  metal  mallets  of  the  instrument-makers. 

The  Modern  Manner  of  Performing  Necrotomy. — The  following  descrip- 
tion may  serve  as  an  elucidation  of  the  technique  of  a  sequestrotomy.  The 
parts  being  well  cleansed  with  soap  and  hot  water,  shaved,  and  disinfected 
by  mercuric  irrigation,  after  Esmarch's  band  is  applied,  an  incision  is  car- 
ried down  to  the  bone  over  or  near  the  fistulae.  The  length  of  the  external 
incision  should  be  proportionate  to  the  extent  of  bone  thickening.  The 
thickened  bone  should  always  be  attacked  where  it  is  most  superficial,  the 
site  of  the  incision  being  determined  rather  hy  the  question  of  accessihility 
than  ly  the  location  of  the  sinuses.  Where  the  bone  is  superficial,  as,  for 
instance,  the  tibia,  the  incision  may  be  at  once  carried  down  to  it.  Where 
there  is  a  thick  mass  of  overlying  soft  tissues,  the  incision  should  be  gradual 
and  preparative,  and  all  cut  vessels  should  be  at  once  ligatured.  The  peri- 
osteum is  pried  up  on  both  sides  of  the  cut  with  an  elevator,  and,  where  it 
is  found  adherent  by  cicatricial  tissue,  is  cut  away,  until  the  entire  affected 
area  is  well  exposed.  Integument  and  periosteum  are  held  back  with  a  pair 
of  Volkmann's  retractors,  and  the  roof  of  the  cavity  containing  the  seques- 
trum is  chiseled  away.  This  can  be  done  very  rapidly  by  a  workmanlike 
use  of  the  mallet  and  chisel,  until  the  sequestrum  is  completely  exposed. 
This  being  done,  the  sequestrum  is  lifted  out  of  its  bed  with  a  pair  of  for- 
ceps. The  irregular  edges  of  the  cavity  are  next  smoothed  off,  overhanging 
parts  are  removed,  so  as  to  permit  a  careful  and  thorough  ocular  examina- 
tion of  all  its  recesses.  Care  must  be  taken  not  to  leave  behind  any  dead 
bone.  The  sharp  spoon  should  be  used  in  vigorous  strokes  to  clear  away  all 
granulations  or  softened  osseous  tisstte,  until  the  entire  wound-surface  pre- 
sents a  bleeding,  clean,  and  healthy  appearance.  Debris  and  shreds  of 
granulations  are  flushed  out  with  a  strong  irrigating  stream,  and,  to  make 
sure  that  no  detached  particles  of  tissue  are  left  behind,  the  cavity  should 
be  mopped  out  with  a  clean  sponge. 

Where  the  operator  is  not  certain  of  having  rendered  the  cavity  perfectly 
aseptic,  it  is  safest  not  to  apply  sutttre,  but  to  fill  it  with  a  loose  pack- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


I'JU 


ino-  of  iodoformed  gauze,  and  to  swathe  the  limb  in  a  moist  compressive 
dressing.  The  dressing  should  be  ample,  and  should  contain  externally  a 
good  layer  of  elastic  material,  as,  for  instance,  ab- 
sorbent cotton.      The  turns  of  the  roller  bandage 


lif 


Fig.  151.  _ 
Carpenters'  chisels 


Fig.  152. 
Boxwood  mallet. 


Fig.  154. 

Volkmann's  sharp 

spoon. 


should  be  tight  and  close,  to  insure  a  sufficient  amount  of  elastic  compres- 
sion as  a  safeguard  against  secondary  haemorrhage.  Ample  padding  will 
prevent  strangulation.  After  the  dressing  is  finished,  the  limb  is  held  ver- 
tically while  Esmarch's  band  is  removed. 

Note.— No  alarm  need  be  felt  if  the  finger-tips  or  toes  do  not  turn  pink  at  once.  A 
momentary  lowering  of  the  limb  will  immediately  produce  the  flush  indicative  of  the  hyperemia 
due  to  paresis  of  the  vasomotor  nerves. 

Vertical  elevation  by  suspension  or  propping  up  should  be  maintained  for 
two  or  three  hours,  till  a  firm  clot  form  in  the  wound.  Should  some  blood 
permeate  the  dressings  and  appear  on  their  surface  a  short  time  after  the 


200 


RULES   OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


operation,  then  snfficient  pressure  was  not  employed.  Suitable-sized  com- 
presses of  iodoformed  and  sublimated  gauze  should  at  once  be  laid  upon 
the  blotch,  and  should  be  firmly  held  down  by  a  clean  elastic  or  flannel 
bandage.  This  additional  pressure  by  the  elastic  bandage  should  not  last 
more  thau  an  hour. 

Case. — Herman  Albertin,  school-boy,  aged  nine.  Central  sequestrum  of  lower  end 
of  shuft  of  humerus  and  disseminated  necrosis  of  lower  epiphysis  due  to  acute  osteomye- 
litis. Necrotomy  performed  April  12,  1884,  at  German  Hospital,  under  chloroform. 
A  longitudinal  incision  five  inches  long,  commencing  at  the  upper  third  of  the  posterior 
aspect  of  the  left  humerus,  was  successively  carried  through  the  skin,  fascia,  and  triceps 
muscle,  until  the  musculo-spiral  nerve  was  exposed  and  freed  from  its  bed.  It  was 
taken  up  and  held  aside  by  a  blunt  hook.  The  periosteum  was  incised,  turned  aside, 
and  held  up  by  u  pair  of  Volkmann's  four-pronged  hooks.  The  posterior  face  of  the 
thickened  shaft  of  the  humerus  was  chiseled  away,  exposing  an  irregular-shaped 
central  sequestrum,  three  inches  long.  The  overlapping  parts  of  the  involucrum  were 
further  chiseled  off,  until  the  entire  sequestrum  could  be  easily  lifted  out  of  its  place. 
Two  small,  round  sequestra  were  removed  from  the  lower  epiphysis,  and  the  entire 
trough-shaped  cavity  was  carefully  scraped  out  with  a  sharp  spoon.  A  small  strip  of 
iodoformed  gauze  was  placed  into  the  most  dependent  part  of  the  bone  detect,  and  was 
brought  out  at  the  lower  angle  of  the  wound.  The  triceps,  fascia,  and  skin  were 
united  by  three  tiers  of  continuous  catgut  suture.  A  compressive  gauze  dressing  was 
bandaged  around  the  limb,  and  the  constricting  band  was  removed.  The  ai'm  was 
held  in  vertical  suspension  for  two  hours,  and  after  that  was  placed  in  the  semi-elevated 
posture  on  a  pillow.  The  temperature  remained  normal  throughout.  The  first  change 
of  dressings  was  made  April  26th,  a  fortnight  after  tlie  operation.  The  dressings  con- 
tained only  a  small  quantity  of  dried  blood.  The  fillet  of  gauze  being  removed,  a  new 
dressing  was  applied.  The  patient  was  discharged  from  the  hospital  April  30th,  with 
a  small,  superficially  granulating  wound  corresponding  to  the  place  of  drainage.     He 

returned  for  another  change  of  dressing  May  12th,  when 
the  wound  was  found  entirely  cicatrized  over. 

In  cases  where  the  surgeon  is  reasonably  sure 
of  having  produced  an  aseptic  wound,  either 
Neuber's  method  of  implantation  of  skin-flaps 
or,  what  is  better,  Schede's  treatment  can  be 
employed. 

Neuher's  Metliod  of  Implantation. — Neuber's 
idea  consists  in  the  endeavor  to  cover  up  with 
skin,  if  possible,  all  the  raw  surfaces  left  by  the 
operation.  Primary  union  is  the  object,  and  a 
minimum  of  uncovered  raw  tissues  is  left  to  heal 
by  granulation.  Longitudinal  bone  defects,  such 
as  are  caused  by  the  removal  of  a  necrosed  por- 
tion of  the  shaft,  are  partly  or  entirely  covered 
by  the  turning  in  of  the  edges  of  the  cutaneous  ivound  till  they  meet  at  or 
near  the  bottom  of  the  groove  in  the  bone  (Fig.  149).  It  is  necessary  for 
this  purpose  to  dissect  up  laterally  the  skin  on  both  sides  of  the  incision  to 
a  goodly  extent,  so  as  to  render  it  movable  and  easily  held  in  the  new  posi- 
tion.    One  or  more  wide  sutures  of  catgut  are  passed  through  the  skin  at 


[/ 


Fir..  155. — Simon  Nathan's  case. 

A,  Feno.stral   defect  of  tibia. 

B,  Bridge  removed. 


DIAGNOSIS  AND   TREATMENT   OF  PHLEGMON. 


201 


the  points  of  reflection  (Fig.  149),  to  retain  the  tlaps  in  position  ;  and,  where 
this  is  not  sufficient,  a  well-disinfected  nail  is  driven  through  the  edge  of 
tlie  flap  into  the  bone.  The  groove  thus  formed  is  loosely  packed  with 
strip^:  of  iodoform  gauze,  and  tiie  limb  is  incased  in  an  aseptic  dressing. 

Note. — Nails  are  disinfected  either  by  boiling  in  water 
or  by  being  passed  through  an  aleohol-flame  till  they  as- 
sume a  dull-red  heat.  After  this  they  are  dropped  into 
the  vessel  holding  carbolic  lotion  and  the  instruments. 

Case  I. — Simon  Nathan,  clerk,  aged  nineteen, 
admitted  to  the  German  Hospital  April  18,  1886. 
Had  been  operated  on  three  years  ago  for  necrosis 
of  tibia  by  Prof.  Schonborn,  of  Konigsberg.  A  fist- 
ula remained  on  the  anterior  aspect  of  the  leg,  that 
closed  up  and  broke  open  several  times  every  year. 
The  probe  detected  exposed  but  smooth  bone.  April 
22cl. — The  patient  was  anaesthetized  and  the  tibia 
was  exposed.  It  was  found  that  the  sinus  led  into  an 
oblong  defect  (Fig.  155)  of  the  shaft,  througli  which 
the  probe  could  be  passed,  so  as  to  be  clearly  felt 
beneath  the  soft  tissues  of  the  calf.  The  length  of 
this  defect  was  a  little  more  than  an  inch,  its  width 
half  an  inch,  and  its  walls  were  formed  by  very  hard 
condensed  bone.  Apparently  the  sclerosed  condition 
of  this  hone  and  its  scanty  blood-supply  was  the  cause  of  the  frequent  ulceration  of 
the  deciduous  granulations  forming  within  the  track.  The  bridge  of  sclerosed  bone, 
together  with  the  adjacent  condensed  parts  of  the  shaft,  were  removed  by  mallet 
and  chisel ;  the  edges  of  the  cutaneous  wound  were  dissected  up  sufficiently  to  admit 
of  an  easy  adjustment  within  the  gap  between  the  tibia  and  fibula  (Fig.  156).  Two 
stout  catgut  sutures  were  passed  through  both  edges  of  the  skin-wound,  and  were 
brought  out  by  a  Peaslee's  needle  on  the  under  side  of  the  calf,  wliere  they  were  firmly 


Fig.  156. — Simon  Nathan's  case. 
Implantation  of  cutaneous  edges 
into  the  defect  by  transfixing 
catL'Ut  suture.  • 


Fig.  157. — Neuber's  method.     Frank  NagenL'ast's  case.     Implantation  of  triangular  flap  into  the 

defect  of  the  head  of  tibia. 


knotted  over  a  piece  of  stout  drainage-tube.  Thus  the  edges  of  the  skin-flaps  were 
well  drawn  into  the  bottom  of  the  defect.  To  somewhat  relieve  the  pressure  by  the 
drainage-tube  upon  the  skin  of  the  calf,  a  nail  was  driven  through  one  of  the  flaps  into 
the  tibia,  and  the  leg  was  dressed  antiseptically.  Slight  elevations  of  the  temperature 
without  general  or  local  discomfort  were  observed  on  tlie  two  successive  days,  after 
which  the  normal  standard  remained  unchanged.     The  dressings  were  removed  May 


202 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


9th,  and  the  skin-flaps  were  found  firmly  adherent  in  their  new  position.  Some  cutane- 
ous ulceration  of  the  skin  on  the  calf  had  taken  place.  The  nail  was  removed.  The 
patient  was  discharged  cured  June  1st. 

Note. — A  sclerosed  and  ill-nourished  state  of  the  involucrum  will  often  lead  to  a  repeated 
breakdown  of  the  granulations  lining  an  old  sinus.  Stimulating  injections  will  sometimes  effect 
a  cure,  but  in  rebellious  cases  success  can  be  had  onl)'  from  a  thorough  removal  of  the  condensed 
poi'tions  of  the  bone  and  sinus. 

Case  II. — Frank  Nagengast,  aged  eight,  a  very  anssmic  boy.  Necrotomy  of  tibia, 
November  2,  1885,  at  Mount  Sinai  Hospital.     Extraction  of  a  large  central  sequestrum 


Fig.  158. — Diagram  illustrating  Scbede's  method  applied  to  a  case  like  that  of  Frank  Nagengast. 

comprising  the  entire  thickness  of  the  upper  half  of  the  shaft,  a  narrow  extension 
reaching  down  to  the  lower  epiphysis.  Three  small  sequestra,  together  with  a  lot  of 
softened  granular  cancellous  tissue,  were  removed  from  the  head  of  the  tibia.  The 
remaining  posterior  portion  of  the  involucrum  was  so  slender  and  brittle  that  it  broke 

into  several  fragments  during  the 
operation.  Lateral  implantation 
of  the  skin  by  means  of  transfix- 
ing sutures  by  Peaslee's  needle. 
Antiseptic  dressing  and  a  lateral 
splint.  First  change  of  dressings 
November  23d.  Healing  of  the 
wound  by  adhesion  correspond- 
ing to  the  .shaft.  Sinuses  lead- 
ing into  narrow  cavity  in  lower 
portion  of  tibia,  and  a  larger 
cavity  in  the  head  of  the  bone. 
Fractures  united  with  some  sag- 
ging of  tibia  downward.  De- 
cemher  17th. — Bloody  roinfrac- 
tion  of  tibia  ;  scraping  of  upper 
and  lower  cavities.  January  10, 
1(SS6.— Lower  sinus  closed;  up- 
per cavity  shows  no  tendency  to  heal.  February  22,  1886. — Osteo2)lastic  closure  of 
cavity  in  head  of  ti?na  accordinfj  to  Neiiber.  A  triangular  skin-flap,  containing  the 
insertion  of  the  quadriceps  tendon  and  the  periosteum,  was  raised  from  the  anterior 
aspect  of  the  tibia.     The  remaining  roof  of  the  cavity  was  removed  by  mallet  and 


Fig.  159. — Frank  Nagengast's  case,  a.  Triangular  skin- 
tiap.  B,  Skin- flap  turned  into  the  cavity ;  the  dark 
S7>ace  to  heal  by  granulation,  c,  View  of  necrotomy 
wound  treated  according  to  Sehede'.s  method. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


203 


chisel.  Previous  to  this  tlie  capsule  of  the  knee-joint  was  carefully  exposed  to  avoid 
entering  the  joint.  The  granular  lining  of  the  cavity  vv^as  gouged  away,  and  only  a 
shell,  consisting  of  the  articular  surface  and  the  posterior 
portion  of  the  head  of  the  tibia,  remained  intact.  The  tri- 
anguhir  skin-flap  was  turned  down  into  the  bottom  of  this 
cavity,  and  there  attached  by  a  nail  (Figs.  157-161).  The 
remaining  uncovered  Y-shaped  portion  of  the  wound  was 
left  to  granulate.  Under  an  antiseptic  dressing  firm  union 
of  the  flap  to  the  underlying  bone  took  place,  and  the  granu- 
lating part  of  the  wound  was  firmly  cicatrized  over  by  the 
middle  of  April. 

Schede's  Method  (Fig.  162). — Schede's  plan  has 
the  great  advantage  over  Neuber's  method  that  it 
can  be  employed  successfully  under  the  most  vary- 
ing conditions.  Its  simplicity  and  independence  of 
the  presence  or  absence  of  a  sufficient  covering  by  skin 
commend  it  to  the  attention  of  the  surgeon.  The 
author  found  ISTeuber's  plan  inadequate  where  much 
integument  had  been  lost,  and  was  replaced  by  an 
extensive  cicatrix. 


Case  I. — Frank  Hyman,  aged  twelve,  received,  in  May, 
1886,  a  blow  on  the  left  tibia,  after  which  central  osteomye- 
litis developed.  August  9tJi. — Necrotomy.  Two  large  se- 
questra were  removed  from  the  upper  half  of  the  shaft, 
requiring  three  separate  parallel  incisions  for  their  extraction, 
carefully  evacuated  of  all  granulations,  and  disinfected  with  a  1 

rosive  sublimate. 


■ 

1 

1 

rj^B 

1 

k 

Fig.  160. — Anterior  view 
of  Frank  IS'agengast's  leg 
after  com]ileted  cui's. 


The  wound  was  very 
1,000  solution  of  cor- 
Simple  suture  of  the  cutaneous 
incisions;  a  small  drainage-tube  was  placed  into 
the  upper  angle  of  the  longest  incision.  All  the 
incisions  were  covered  with  strips  of  disinfected 
rubber  tissue,  and  the  limb  was  dressed  with  sub- 
limated gauze.  The  first  dressing  remained  un- 
changed for  four  weeks,  when  only  a  shallow  fist- 
ula remained  at  the  place  where  the  drainage-tube 
had  lain.  This  was  scraped,  and  it  promptly  healed. 

The  large  cavity  became  filled  with  a 
blood-clot,  which  organized  without  sup- 
puration. 

The  treatment  of  the  osteomyelitic  pro- 
cesses of  t\\Q  femur  and  their  sequelae,  nota- 
bly of  necrosis,  presents  peculiar  difficulties 
of  technique  mainly  due  to  the  deep  site  of 
the  bone.  Long  incisions  are  usually  indis- 
pensable, access  to  the  remote  portions  of 
the  bone  is  difficult,  and  the  necessary  injury 
to  many  muscular  branches  of  the  femoral  artery,  and  the  difficulty  of  effect- 
ive compression  of  the  muscular  masses,  render  the  question  of  after-haem- 
orrhage rather  serious.    It  is,  therefore,  advisable  not  to  deplete  the  limb  by 


Fig. 


161. — Lateral  view 
Nagengast's  leg 


:)f  Frank 


204 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


an  elastic  bandage  of  ail  its  blood  before  applying  Esmarch's  constriction. 
Each  cut  vessel  will  then  pour  out  a  small  quantity 
of  blood,  and  can  be  readily  seen  and  deligated. 
The  safest  approach  to  the  hone  is  from  the  external 
aspect,  preferably  above,  or  below  the  ham-strings. 
On  the  inner  side,  Hunter''s  canal  requires  careful 
attention  on  account  of  the  femoral  artery.  The 
sequestrum  is  generally  located  near  the  posterior 
aspect  of  the  lower  end  of  the  shaft.  Should  it  even 
occur  that  the  popliteal  abscess  perforate  on  the  in- 
ner aspect  of  the  thigh,  exposure  of  the  sequestrum 
from  the  external  side  will  be  safer  and  more  easy. 
By  the  free  use  of  the  chisel  and  mallet,  sufficient 
access  can  be  gained  to  remove  the  sequestrum. 
Even  the  most  expert  operator  will  occasionally  fail 
to  find  a  small  sequestrum,  or  will  not  succeed  in 
its  entire  removal.  The  eventual  necessity  of  a  repe- 
tition of  the  operation  should  be  pointed  out  from 
the  outset  to  the  patient. 

Inferior  Maxilla. — As  a  rule,  osteomyelitic  foci 
of  the  lower  jaw  communicate  with  the  oral  cavity. 
This  makes  the  preservation  of  the  aseptic  condition 
of  the  wound  rather  difficult,  and  sometimes,  notably 
in  the  presence  of  a  neglected  and  foul  set  of  teeth, 
an  impossibility.  Where  the  process  is  extensive,  an 
external  incision  is  preferable,  as  it  lessens  the  dan- 
oer  of  the  entrance  of  blood  into  the  respiratory  tract, 
and  facilitates  complete  and  clean  work. 


Fig.  102. — Illustratini;  successive  steps  of  Scliede's  dressing,  a,  Necnitnuiy  wound,  b,  Protect- 
ive, c,  lodoforiiK'd  jziiuze.  i>,  Sublimute  frauze.  e,  ('om]ilete  dressiii<r.  (Case  of  Sumuel 
Krongold.     Photoj^raplis  taken  ten  days  after  operation.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  205 

Case. — I.  Eckert,  tailor,  aged  twenty-tliree,  contra(;teJ  traumatic  ac;;te  osteoinve- 
litis  of  tlie  horizontal  ramus  of  the  left  side  of  the  lower  jaw,  after  the  extraction  of  a 
carious  tooth,  done  November  2,  1886.  The  intense  pain  of  the  beginning  was  relieved 
by  a  spontaneous  discharge  of  pus  into  the  oral  cavity.  The  author  saw  the  patient 
November  23d,  when  the  thickening  of  the  Jaw,  the  profuse  secretion,  and  direct  prob- 
ing put  the  presence  of  a  sequestrum  beyond  doubt.  Sequestrotomy  ■performed  Novem- 
her  25t1i.  The  month  had  been  prepared  for  a  day  or  two  by  frequent  rinsings  with 
salt  water;  the  face  had  been  shaved.  The  back  of  the  auaasthetized  patient's  head 
was  rested  on  a  low,  hard  roll  made  of  a  blanket.  The  hair  was  wrapped  up  in  a  hood 
made  of  a  towel  dipped  in  corrosive  sublimate,  the  chest  protected  by  another  wet 
towel.  The  skin  of  the  jaw  was  well  soaped  and  rubbed  off  with  mercuric  lotion. 
Then  an  incision  two  inches  and  a  half  in  length  was  made  along  the  lower  edge  of  the 
horizontal  ramus.  The  facial  artery  was  exposed,  separated,  secured  by  two  pairs  of 
artery  forceps,  cut  through  between,  and  doubly  deligated.  The  periosteum  was 
incised  to  the  entire  length  of  the  external  cut,  and  was  reflected  upward  witb  an  ele- 
vator. Before  opening  into  the  oral  cavity,  a  sponge  held  by  a  long  sponge-holder 
was  thrust  into  the  naouth  to  the  vicinity  of  the  fistula,  to  receive  any  blood  that  might 
escape  that  way.  An  oblong  quadrangle  of  the  external  lamella  of  the  alveolar  process 
and  body  of  the  ramus  was  chiseled  away,  exposing  a  cavity  containing  three  sequestra 
and  a  mass  of  ulcerating  fetid  granulations.  The  cavity  was  carefully  scraped  out  by 
the  sharp  spoon,  irrigated  with  corrosive  sublimate,  the  soiled  sponge  in  the  mouth 
having  first  been  substituted  by  a  clean  one.  The  opening  freely  communicating  with 
the  oral  cavity  was  plugged  with  a  strip  of  iodoformed  gauze,  that  reached  just  within 
the  focus ;  the  external  wound  was  closed  by  a  number  of  catgut  stitches,  a  short  drain- 
age-tube being  first  placed  in  its  posterior  angle.  Becemiber  ^(Z.— First  change  of  dress- 
ings. No  reaction ;  no  fever.  External  wound  was  found  closed,  the  drainage-tube 
was  shortened,  and  was  found  still  containing  a  dark-red  blood-clot.  The  iodoform  plug 
was  left  undisturbed,  and  was  removed  by  the  patient's  family  attendant  at  the  end  of 
the  second  week.     Discharge  was  scanty  throughout.     Patient  cured  December  20th. 

Bone  Abscess. — Circumscribed  acute  osteomyelitis  of  minor  intensity, 
caused  very  likely  by  infection  with  a  very  limited  number  of  micrococci 
deposited  in  the  medullary  substance  from  the  blood,  does  not  have  a  pro- 
nounced tendency  to  induce  massive  necrosis.  Breaking  down  and  emul- 
sification  of  the  affected  parts  are  tardy,  and  thus  opportunity  is  given 
to  the  surrounding  tissues  for  throwing  up  around  the  focus  a  protective 
wall  of  granulations.  The  extension  of  the  abscess  is  slow,  and  the  local 
as  well  as  general  disturbance  effected  by  it  is  of  a  chronic  character. 
Nightly  exacerbations  of  fever,  with  occasional  chills  and  sweats,  and  local- 
ized, deep-seated  pain  of  a  throbbing  nature,  gradual  hypertrophy  of  the 
bone,  with  atrophy  of  the  pertinent  muscles,  trophic  changes  of  the  skin, 
as  glossiness  and  local  sweats,  and  increasing  emaciation,  are  the  character- 
istic symptoms  of  the  affection,  which  extends  over  months  and  even  years. 
The  marked  thickening  of  the  bone,  the  spontaneous  local  pain,  augmented 
by  pressure  on  percussion,  and  the  absence  of  fistula  are  mainly  to  be  con- 
sidered as  to  diagnosis.  Therapy  consists  in  doing  what  is  to  be  done  with 
all  abscesses — evacuation  and  eventually  drainage. 

The  conspicuous  thickening  of  the  bone  serves  as  a  convenient  guide  to 
the  purulent  focus.  After  the  application  of  Esmarch's  constrictor,  a  free 
28 


2UG 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


incision,  made  according  to  the  rules  described  in  the  jiaragraph  on  iiecroto- 
mj,  exposes  the  bone,  the  surface  of  which  is  generally  found  covered  with 
osteophytic  excrescences,  that  somewhat  impede  the  raising  up  of  the  peri- 
osteum. All  the  soft  parts  being  held  away  by  sharp  retractors,  the  thick 
layer  of  new-formed  bone  is  pared  off  with  the  chisel,  layer  by  layer,  until 
the  cavity  containing  pus  is  exposed.  Sometimes  a  number  of  discrete  or 
communicating  foci  are  present,  and  the  surgeon  must  make  sure  of  not 
overlooking  any  of  them.  It  is  best,  accordingly,  to  expose  the  medullary 
space  throughout  the  entire  extent  of  the  thickening.  By  entirely  removing 
tlie  roof  of  the  cavity,  it  is  converted  into  a  more  or  less  shallow  trough, 
all  parts  of  which  are  exposed  to  ocular  inspection.  The  smooth  pyogenic 
membrane  lining  the  abscess  is  carefully  removed  to  its  last  shred  by  vigor- 
ous scraping  and  gouging  with  the  sharp  spoon,  and  by  subsequent  irriga- 
tion. A  final  flushing  of  the  wound  with  a  strong  (1  :  500)  solution  of 
corrosive  sublimate  will  make  sure  of  the  destruction  of  all  lingering  germs. 
The  wound  is  sutured  and  dressed  according  to  Schede's  plan,  and,  if  the 
removal  of  all  diseased  tissues  and  infectious  secretions  was  thorough,  rapid 
and  uninterrupted  healing  under  the  blood-clot  will  take  place. 

Case  I. — Richard  Boss,  metal-worker,  aged  thirty-eight.     Chronic  painful  thick- 
ening of  the  shaft  of  the  humerus  of  two  years'  standing.    Glossy  skin,  atrophy  of  the 
muscles  of  the  arm  and  forearm,  formication,  and  hyperidrosis,  together  with  paretic 
symptoms     affecting 
principally  the  mus- 
culo -  spiral      nerve. 
Nightly       exacerba- 
tions  of    local  pain 
and    hectic    emacia- 
tion.     February    2, 
1887.— At   the   Ger- 
man Hospital,  expos- 
ure   by    chisel    and 
mallet  of  a  bone  ab- 


h'm.  16-5.  —  Exposure  nf  thickened  humerus  containinir  a  central  bone  abscess.  Ehistic  constrictor 
tied  above  the  acromion,  and  tiience  passed  around  thorax  into  the  opposite  armpit,  where 
it  is  secured  by  another  ligature. 


scess  occupying  the  middle  and  upper  part  of  the  medullary  cavity  of  the  left  hume- 
rus. Schede's  method  of  dressing  the  wound.  Fehruary  17th. — First  change  of  dress- 
ings.    Wound  united   by  tiie  first   intention.      Two  su])erficial  drainage-tubes  were 


DIAGNOSIS  AND  TREATMENT  OP  PHLEGMON. 


2or 


removed .  Ma  rcli  6  th.  — 
Patient  discharged  per- 
fiH'tiy  cured  with  im- 
proving function  of  the 
extremity.  (Figs.  l(Jo, 
16-1:,  and  165.) 

Case  II.  —  Samuel 
Krongold,  school  -  boy, 
aged  twelve,  had  had, 
several  years  ago,  com- 
jjound  dislocation  and 
acute  suppuration  of  the 
left  elbow-joint,  compli- 
cated with  acute  osteo- 
myelitis of  the  lower 
epiphysis  of  the  hume- 
rus, in  consequence  of 
which  several  sequestra 
had  to  be  removed  by  the 
author.  Three  months 
ago  a  painful  thickening 
of  the  shaft  of  the  hu- 
merus appeared,  causing 
marked  deterioration  of 
the  boy's  health.  February  18,  1887. — At  the  German  Hospital,  a  central  bone  abscess 
occupying  the  middle  portion  of  the  medullary  space  of  the  humerus  was  exposed  and 
evacuated,  and  was  treated  by  Schede's  method.  February  26th. — The  first  change  of 
dressings  took  place,  and  the  entire  wound  was  found  healed  with  the  exception  of 
the  slit  le^t  open  for  drainage  at  the  lower  angle  of  the  wound,  which  was  occluded  by  a 


Fio.  164. — Cavity  chiseled  open.     Its  contents  removed  with  the 
'  sharp  bpoon.     (Eichard  Boss.) 


f  resli  -  looking  blood  -  clot. 
March  6th.  —  Patient  dis- 
charged completely  cured. 
(Fig.  162.) 

The  remarkably  short 
and  complete  cure  of 
both  of  these  cases  is 
undoubtedly  to  be  at- 
tributed to  the  adoption  of  Schede's  plan.  Plugging  of  and  introducing 
drainage-tubes  or  any  foreign  substance  into  the  bone  cavity  are  done  away 


Fig.  165. — Eichard  Boss's  wound  treated  accordins:  to 
Schede's  method.  Photograph  taken  February  ITth, 
fifteen  days  after  operation. 


20S  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

witli.  and  organization  of  the  massive  blood-clot  goes  on  uninterruptedly 
to  the  greatest  advantage. 

Conclusions. 

Prevention  of  infection  contains  the  spirit  and  aim  of  ctseptic  surgery ; 
the  object  of  antiseptic  surgery  is  disinfection  and  the  conservation  of 
infected  tissues.  The  first  object  is  attained  by  a  severe  discipline  of  clean- 
liness ;  the  second  by  the  still  more  severe  discipline  of  early  incisions  and 
adequate  drainage  and  disinfection. 

A  clear  comprehension  of  the  processes  determining  suppnratioii  must 
result  in  the  firm  conviction  that  an  early  and  free  incision  of  every  focus 
of  septic  inflammation  is  the  most  conservative  form  of  treatment.  It  pre- 
vents local  death  and  general  intoxication,  the  latter  only  too  often  the 
cause  of  general  death.  If  this  conviction  will  have  entered  into  the  "  suc- 
cum  et  sanguinem'"  of  every  physician,  public  opinion  will  gradually  yield 
to  a  better  understanding  of  individual  and  the  public  interest. 

Note. — The  change  in  the  surgeon's  attitude  toward  the  employment  of  incisions  for  septic 
inflammative  processes  is  characterized  by  these  sentences  : 

Formerly,  topical  applications  were  the  main  reliance,  incision  only  a  last  and  extreme 
resort.     Tlie  surgeon  had  to  show  cause  why  an  incision  should  he  made. 

At  present,  relief  from  tension  and  escape  of  the  noxious  substances  through  incision  and 
drainage  is  the  clear  indication  to  be  fulfilled.  The  surgeon  must  show  cause  why  an  incision 
should  not  he  made  in  the  presence  of  septic  inflammation. 

2.  Plilegmonous  Affections  of  some  Special  Regions. 
a.  Face.    Floor  of  the  Mouth.    Neck.    Temporal  and  Mastoid  Regions  : 

Anatomical  Arrangement  of  the  Connective-Tissue  Planes  of  the  Neck. — Henke's 
classical  essay  is  the  best  guide  for  the  clear  comprehension  of  this  subject.  He  injected 
the  different  interspaces  of  a  cadaver  with  liquid  gelatin,  and  studied  the  manner  of 
its  extension  between  the  several  organs  by  exposing  the  congealed  masses,  and  examin- 
ing their  relations  in  situ.  The  chief  interspaces  of  the  neck  are  classified  by  Henke 
as  follows : 

1.  The  Capsule  of  the  Submaxillary  Salivary  Gland. — It  forms  a  completely  closed 
envelope  to  the  gland,  from  which  continuations  extend  to  the  superficial  and  deep 
cervical  fasciae. 

2.  '•'■  Previsceral  Interspace.''^ — The  connective-tissue  plane  or  interspace  situated 
between  the  prelaryngeal  group  of  longitudinal  muscles  (hyo-thyroids,  sterno-hyoids, 
and  sterno-tLyroidsj  anteriorly,  and  the  larynx,  thyroid  gland,  and  trachea  posteriorly. 
It  communicates  with  the  anterior  mediastinum.  Perforation  of  a  suppurating  thyroid 
gland  leads  to  invasion  of  this  space,  with  subsequent  compression  of  the  trachea. 
(Fig.  166,  0.) 

Cask. — S.  C,  aged  seventeen.  The  patient  was  treated  by  Dr.  C.  Lellmann  for  typhoid  fever 
in  the  German  Hospital.  In  the  third  week  of  the  disease  severe  dyspnoea  developed,  with  a 
peculiar  wheezing  sound  accompanying  respiration.  On  examination,  a  diffuse  swelling  was 
noted  in  front  of  the  neck.  Incisi(m  evacuated  an  abscess  communicating  with  the  interior  of 
the  thyroid  gland,  whence  perforation  must  have  taken  place.     Immediate  relief  followed. 

3.  "  Retrovisceral  Interspace.'''' — The  interspace  between  the  pharynx  and  oesoi)h- 
agus  in  front,  and  the  vertebral  column  behind.  It  communicates  witli  the  posterior 
mediastinum.    (Fig.  106,  a.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


209 


4.  '■'■  Perirascular  Intempace.'' — Tlie  interspace  containing  the  carotid  artery  and 
jugular  vein.  It  communicates  with  the  anterior  mediastinum  along  the  course  of  the 
large  vessels,  and  is  important  on  account  of  the  frequent  sup])uration  of  the  group  of 
lymphatic  glands  sit- 
uated in  front  of, 
and  externally  to 
the  jugular  vein. 
Abscesses  of  this  in- 
terspace displace  the 
sterno-mastoid  mus- 
cle outward;  they 
extend  along  the 
vessels  downward, 
and,  left  to  them- 
selves, either  per- 
forate through  the 
deep  and  the  super- 
ficial fasciaB  and  the 
skin  near  the  clavi- 
cle, between  the  low- 
er end  of  the  sterno- 
mastoid  muscle  and 
the  trachea,  or  make 
their  way  along  the 
vessels  into  the  an- 
terior mediastinum. 
(Fig.  167.) 

5.  '"'' Intermuscu- 
lar SpaceP — An  interspace  situated  at  their  crossing,  between  the  lower  third  of  the 
sterno-mastoid  and  the  omo-hyoid  muscles.     This  space  owes  its  origin  to  the  sliding 

of  these  contiguous  mus- 
cles upon  each  other,  and 
is  limited  posteriorly  by 
the  scaleni.  It  contains  a 
group  of  lymphatic  glands, 
seated  near  the  posterior 
edge  of  the  lower  third  of 
the  sterno-mastoid  muscle 
(supraclavicular  glands), 
and  communicates  inward 
and  upward  with  the 
retrovisceral  space,  and 
along  the  subclavian  ves- 
sels with  the  axillary  cav- 
ity. Supraclavicular  ab- 
scesses usually  extend  into 
the  arm-pit.     (Fig.  168.) 


Fig.  1G6. — c,  Previsceral  space. 
Antero-postcrior  section. 


t,  Eetrovisceral  interspace. 
(From  Henke.) 


STERNOTHYROtD\ 
SUBCUTANIAN 


OMOHYOID 

STERNOHYOID 

-  _v 


CAROTID 

I 

-      JUGULAR 


TRAPEZIUS 


Fio.  167.- 


-Perivascular  interspace. 
(From  Heuke.) 


Transverse  section. 


{a)  Face.  —  The 
most  serious  form  of 
cutaneous  and   subcu- 


210 


RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 


S  TFPNOMA  STOID 


Fig.  168. — Intermuscular  space.     Lateral  antero-posterior  section. 
(From  Henke.) 


taneous  phlegmon  observed  on  the  face  is  tlte  carhuncle.  It  is  characterized 
by  a  dense,  hard  swelling  of  conical  shape,  extending  far  into  the  subcu- 
taneous connective  tis- 
sue. It  has  a  dusky 
red  color,  and  its  apex 
is  marked  by  one  or 
more  yellowish  discol- 
ored spots,  which  are 
surrounded  by  a  bluish 
halo.  Septic  thrombo- 
sis extending  through 
the  Jugular  veins  into 
the  cranium  is  to  be 
feared  in  this  affec- 
tion. The  systemic  in- 
toxication is  generally 
very  intense,  high  fe- 
ver being  the  rule.  In 
some  of  the  worst  cases  the  intoxication  is  so  deep  as  to  cause  symptoms  of 
collapse,  with  low,  sometimes  even  subnormal,  temperatures. 

In  this  condition  an  early  and  most  energetic  treatment  is  urgently 
indicated,  and  is  almost  always  followed  by  elimination  of  the  infectious 
process. 

A  crucial  incision,  or,  in  extensive  cases,  a  number  of  parallel  incisions, 
carried  in  length  and  depth  beyond  the  indurated  area,  will  relieve  tension 
and  permit  the  escape  of  the  contents  of  many  smaller  or  larger  incarcerated 
foci.  The  incisions  should  be  packed  lightly  with  strips  of  iodoformed 
gauze.  In  cases  of  anaemia,  where  loss  of  blood  would  materially  increase 
the  danger,  the  actual  cautery  should  be  so  applied  as  to  convert  the  entire 
infected  area  into  a  dry  eschar.  This  or  the  incisions  should  be  envelojjed 
in  a  moist  dressing,  which  has  to  be  renewed  according  to  the  amount  of 
secretions. 

Note. — The  following  bloodless  treatment  applied  by  Slesarewskij  in  forty-four  cases  of  car- 
buncle seems  to  deserve  trial,  as  it  yielded  very  good  results  in  his  hands :  Inspissated  crusts  are 
first  removed,  then  the  diseased  surface  is  sprinkled  with  from  thirty  to  sixty  grains  of  corrosive- 
sublimate  powder.  The  dusky  halo  surrounding  the  center  of  the  sore  is  thickly  covered  with 
blue  ointment,  and  the  whole  is  enveloped  in  a  compress  soaked  in  carbolized  oil  (1  :  10),  fast- 
ened with  a  roller  bandage.  In  case  of  severe  pain,  an  ice-bag  is  placed  over  the  dressing.  The 
following  day,  corresponding  to  the  application  of  the  mercuric  salt,  a  gray,  very  dense  eschar 
will  be  visible,  which  will  separate  ten  days  later,  and  will  be  followed  by  rapid  healing. 
Slesarewskij  never  observcid  mercuric  intoxication  d\iiing  or  after  the  application  of  this  mctiiod 
of  treatment.     ("Centralblatt  fiir  Ohirurgie,"  1886,  p.  805.) 

Case. — 'I'he  author  lost,  of  a  considerable  niiiiiber  of  cases  treated  by  incision,  only 
one  by  septic  phlebitis  of  the  right  lateral  sinus.  The  patient,  a  middle-aged  cigar- 
maker,  was  seen  in  consultation  with  Dr.  L.  Weiss,  and  an  enormous  carbuncle  occupy- 
ing the  right  side  of  the  upper  lip  and  cheek  was  fonnd,  with  extensive  oedema  of  the 
eyelids  and  the  right  side  of  face  and  neck,  which  was  due  to  general  throinbosis  of 


DIAGNOSIS   AND  TREATMENT  OF  PHLEGMON. 


211 


the  pertinent  veins.  Tiie  patient  was  senii-coinatose,  somewhat  cyanosed,  and  had  a 
poor  pulse.  lie  had  obstinately  opposed  any  incisive  treatment  for  six  days,  and  the 
case  seemed  clearly  beyond  the  reach  of  surgical  skill.  The  incisions  caused  very  little 
hivmorrhage,  as  most  of  the  divided  tissues  were  necrosed.  He  died  of  coilai)se  on  the 
seventh  day  of  his  illness. 

The  author  has  never  tried  any  of  the  "maturing"  forms  of  treatment 
in  this  affection,  and  would  unhesitatingly  declare  measures  which  are  apt 
to  stimulate  suppuration,  such  as  poulticing,  to  be  always  risky,  and  some- 
times positively  dangerous. 

(b)  Neck. — (a)  Fauces  and  Pliarynx. — The  tonsils  and  the  connective 
tissue  in  which  they  lie  imbedded  are  the  most  favorite  site  of  superficial 
and  deep-seated  septic  processes.  Diphtheria  is  very  likely  a  microbial 
affection  due  to  the  colonization  of  micrococci  upon  the  surface  and  in  the 
follicles  of  tonsils,  that  are  in  a  state  of  catarrhal  or  scarlatinal  inflammation. 
It  is  characterized  by  superficial  or  deep-going  putrid  necrosis  of  the  affected 
tissues,  often  extending  to  the  pharynx,  larynx,  velum,  pillars,  and  the  nasal 
mucous  membrane,  and  is  generally  accompanied  by  a  serious  general  intoxi- 
cation. The  systemic  intoxication  is  most  prominent  when  parts  having 
an  abundant  supply  of  lymphatics,  as  the  pillars  of  the  fauces,  the  velum, 
l^harynx,  and  nasal  mucous  membrane,  are  involved.  The  scantier  de- 
velopment of  the  tonsillar 


and  laryngeal  lymph-ves- 
sels seems  to  be  the  cause 
of  the  minor  intensity  of 
the  systemic  symptoms  ob- 
served in  affections  local- 
ized in  these  parts.  Char- 
acteristic intumescence  of 
the  deep  cervical  lymph - 
glands  is  a  regular  conse- 
quence of  the  affection  of 
the  first  grouj)  of  localities ;  it  is 
more  rarely  observed  in  purely 
tonsillar  or  laryngeal  diphtheria. 
An  invasion  is  apt  to  leave  be- 
hind a  certain  disposition  to  re- 
newed attacks,  which  is  perhaps 
due  to  the  fact  that  quiescent  spores  of  bacteria  remain  imbedded  in  the 
recesses  of  the  follicles,  to  develop  their  activity  whenever  a  new  catarrhal 
inflammation  and  exudative  process  prepares  the  ground  for  their  multi- 
plication. 

But,  on  the  other  hand,  frequent  attacks,  and  the  accompanying 
formation  of  cicatricial  tissue  within  the  textures  of  the  tonsils,  seem 
to  lead  to  a  certain  immunity  from  the  graver  forms  of  the  disease.  As 
a  rule,  persons  who  never  had  diphtheria  suffer  more  severely  than  those 
who  have  gone  through  many  attacks  ;    and  diphtheria   of   children  for- 


FiG.  169. ^Bacteria  from  case  of  vesical  diphtheria 
witii  putrescence  (700  diameters).     (Koch. » 


212  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

merly  free  from  the  disease  is  a  much  more  serious  condition  than  the 
so-called  habitual  ''  follicular  tonsillitis."  While  a  first  attack  is  usu- 
ally, habitual  follicular  tonsillitis  is  rarely,  complicated  with  glandular 
enlargement. 

The  condition  of  things  here  is  comparable  to  that  which  was  mentioned 
as  the  "habituation  of  the  hands  of  anatomists  to  septic  infection"  (see 
page  183,  Note  I).  The  disease  is  highly  contagious,  hence  isolation  of  the 
patient  is  imperative  wherever  possible. 

Aided  by  a  sustaining  and  stimulating  general  treatment,  the  disinfec- 
tion of  the  local  septic  state  should  be  most  energetically  pursued.  Accord- 
ing to  the  age  and  disposition  of  the  patient,  this  will  have  to  be  done  dif- 
ferently. In  small  children  of  a  good  disposition,  pencilings  of  the  affected 
parts  with  milder  or  stronger  solutions  of  corrosive  sublimate  repeated  every 
hour,  and,  in  case  of  nasal  diphtheria,  hourly  syringing  of  the  interior  of 
the  nose,  should  be  practiced.  A  mixture  of  corrosive  sublimate  0*03, 
alcohol  25*00  (or  one-half  grain  to  the  ounce),  can  be  safely  used  for  pencil- 
ing the  tonsils  and  pharynx.  A  tepid  watery  solution  of  1: 5,000  for  syring- 
ing the  nasal  cavity  will  be  well  borne.  Care  must  be  taken  to  keep  the 
nostrils  well  anointed  with  vaseline  to  prevent  eczema,  and  never  to  use  a 
sliarp,  long-beaked  syringe.  During  the  struggles  of  the  resisting  child  the 
mucous  membrane  is  easily  lacerated,  and  the  hgemorrhage  and  certain  infec- 
tion of  the  part  thus  injured  are  not  indifferent  in  an  affection  where  the 
least  comjDlication  may  suffice  to  fatally  determine  the  case.  The  safest 
manner  of  douching  the  nose  is  by  attaching  to  the  nozzle  of  the  syringe 
a  piece  (six  inches  in  length)  of  soft  rubber  tubing,  such  as  is  used  on 
infants'  feeding-bottles,  its  distal  end  being  first  provided  with  a  few  lat- 
eral holes  cut  into  it  with  scissors.  The  syringe  is  filled  with  the  warm 
lotion,  the  well-greased  flexible  tube  is  introduced  into  the  nostril  and 
pushed  back  until  it  is  felt  to  touch  the  posterior  pharyngeal  wall,  the 
child's  head  is  inclined  forward,  and  then  the  contents  of  the  syringe  are 
briskly  thrown  into  the  nasal  cavity.  The  immediate  reflex  closure  of 
the  larynx  and  isthmus  faucium  will  prevent  the  entrance  of  considerable 
quantities  of  the  lotion  into  these  organs,  and  the  energetic  stream  will 
aid  the  detachment  and  expulsion  of  crusts,  membrane,  and  liquid 
secretions.  On  account  of  the  swollen  condition  of  the  mucous  mem- 
brane, the  entrance  of  acrid  secretions  into  the  Eustachian  tubes  need  not 
be  feared. 

The  throats  of  larger  children  or  grown  persons  can  be  cleansed  by  fre- 
quent gargling  with  a  tepid  solution  of  (1  :  5,000)  corrosive  sublimate,  con- 
taining one  teaspoonful  of  cooking  salt.  The  principal  weight  should  be 
laid  upon  a  frequent  application  of  the  gargle  and  a  stimulating,  nourish- 
ing, general  regime. 

Whenever  the  aspect  of  the  malady  is  very  threatening,  the  apj)li- 
cation  of  the  actual  cautery  to  the  affected  parts  is  advisable.  It  is, 
aside  from  the  necessity  of  a  short  anaesthesia,  a  safe  and  rational  process. 
That  only  a  portion  of    the    patches  are  accessible,  some  of   them  being 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


213 


teyond  the  surgeon's  reach  in  the  nasal  cavity,  is  no  valid  reason  why 
those  that  are  amenable  to  this  very  effective  mode  of  disinfection,  should 
not  thus  be  treated. 

The  best  way  of  cauterizing  the  tonsils  and  pharynx  is  the  following 
one  : 

The  head  of  the  anaesthetized  patient  is  drawn  over  the  underpadded 
edge  of  the  table  until  it  assumes  the  dependent,  or  Rose's,  position  (Fig. 
170).  The  surgeon  introduces  a  bent  tongue-depressor,  or  the  bent  handle 
of  a  tablespoon,  well  back  into  the  fauces,  and  instructs  the  ansesthe- 
tizer  to  keep  the  tongue  out  of  the 
way  by  it.  This  will  expose  the 
pharynx  in  an  admirable  fashion  to 
permit  of  the  exact  and  thorough  ap- 
plication of  the  thermo-  or  galvano- 
cautery  to  the  patches  thus  exposed. 
If  the  disease  be  limited  to  visible 
parts  of  the  oral  cavity,  and  all  the 
patches  can  be  thus  treated,  a  rapid 
improvement  of  the  general  state  of 
intoxication  w.ill,  as  a  rule,  at  once 
follow  the  procedure.  Where  only  a 
part  of  the  patches  is  thus  treated,  the 
improvement  will  not  be  as  complete. 

The  glandular  enlargement  also 
requires  attention,  and  should  be 
treated  as  was  explained  elsewhere. 

If  the  process  descend  to  the  larynx,  very  alarming  dyspnoea  will  grad- 
ually develop.  It  should  be  combated  with  external  hot  applications  to  the 
throat,  and  the  inhalation  of  moist,  warm  air  generated  in  the  sick-room. 
The  patient's  strength  should  be  carefully  husbanded  by  frequent  doses  of 
liquid  nourishment,  and  the  avoidance  of  unnecessary  excitement,  exposure, 
and,  most  of  all,  strong  emetics,  the  abuse  of  which  has  cost  many  a  child's 
life.  In  most  cases  the  membrane  will  get  detached  piecemeal,  or  will 
come  away  in  one  or  more  large  masses,  and  relief  will  follow,  perhaps  only 
to  be  succeeded  by  another  or  several  suffocative  attacks.  As  long  as  there  is 
no  lung  complication,  the  pulse  fairly  good,  intubation  offers  fair  chances  of 
success.  Where  the  patient's  strength  has  been  consumed  by  a  very  long, 
ceaseless  struggle  for  air,  or  the  depressing  use  of  emetics,  the  chances  are 
by  far  more  slender.  Yet  even  the  most  desperate  cases  sometimes  yield 
unexpectedly  good  results.  When  intubation  is  not  feasible,  tracheotomy 
has  to  be  performed. 

Preventive  Treatment  of  Tonsillitis. — The  tonsils  are  the  points  where 
the  first  patches  become  visible  in  most  cases,  and  whence  the  local  infec- 
tion extends  to  other  contiguous  parts.  After  frequent  attacks  of  tonsillitis, 
the  surface  of  the  tonsils  becomes  irregularly  indented  by  cicatricial  retrac- 
tion ;  the  tonsil  itself  is  enlarged,  and  often  yields  on  pressure  one  or  more 
29 


Fio.  170. — Rose's  position.     Head  dependent 
from  the  edge  of  the  operating  table. 


214  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

yellowish  plugs  of  a  very  fetid  clieesy  matter  which  were  contained  within 
the  follicles. 

Note. — Drs.  E.  Gruening  and  S.  Cohn  called  my  attention  to  this  fact,  which  I  have  repeat- 
edly verified. 

These  yellowish  masses  are,  as  shown  by  Gruening,  swarming  with  lep- 
tothrix  and  other  micro-organisms,  and  the  presence  of  these  is  undoubt- 
edly at  the  bottom  of  the  so-called  "disposition"  to  catch  the  disease.  The 
reservoir  of  infecting  material  is  ever  there  ;  the  patient  carries  it  constantly 
with  him,  and  a  catarrhal  hyperemia,  followed  by  some  infiltration  and 
epithelial  erosion,  is  all  that  is  needed  to  develop  a  new  attack  of  "follic- 
ular tonsillitis,"  which  may  not  threaten  its  possessor  with  great  danger, 
but  is  just  as  contagious  to  others  as  any  case  of  diphtheria.  One  observa- 
tion like  the  following  will  carry  much  conviction. 

Two  children  of  the  same  family  had  attacks  of  sore  throat  one  after  the  other. 
The  first,  a  boy  four  years  old,  who  has  had  tonsillitis  a  number  of  times,  exhibited  the 
usual  symptoms  of  his  affection  ;  the  second  one,  a  boy  about  a  year  old,  and  hitherto 
free  from  the  disease,  was  carried  into  the  sick-room  of  the  first  child  by  an  obstinate 
nurse,  and  came  down  the  next  day  with  very  alarming  systemic  symptoms,  high  fever, 
and  somnolence,  exhibiting  a  small  patch  on  his  left  tonsil.  The  first  boy  recovered  in 
about  four  days,  the  usual  length  of  his  attack ;  by  the  time  that  he  was  well,  the  baby 
had  died  under  symptoms  of  most  acute  septicaemia.  A  petechial  rash,  commencing 
on  the  nates  and  feet,  extended  upward,  and  gradually  flecked  the  entire  skin.  The 
patch  on  the  tonsil  had  grown  and  others  had  developed,  the  somnolence  turned  into 
coma,  and  was  followed  by  deatli. 

The  wet-nurse  of  this  child  and  the  cook  of  the  family,  who  had  kissed  the  corpse, 
became  seriously  ill  with  diphtheria ;  especially  the  latter,  whose  condition  was  critical 
for  three  or  four  days.  At  the  same  time,  a  male  servant  and  two  more  members  of 
the  family  contracted  sore  throats  of  various  degrees  of  intensity,  and  the  house  had 
to  be  abandoned.  A  friend  and  his  wife  called  in  the  evening  shortly  after  the  child's 
death  to  pay  a  visit  of  condolence.  The  next  morning  one  of  their  children  was  down 
with  malignant  diphtheria,  and  died  in  a  day  or  two  of  septicsemia. 

Destroying  the  entire  surface  of  the  tonsil,  together  with  the  contents  of 
the  follicles  by  the  application  of  the  actual  cautery,  would  seem  to  be 
rational,  and  has  been  found  a  safe  and  effective  measure  for  lessening  the 
disposition  to  renewed  attacks  of  diphtheria.  It  is  infinitely  safer  than  a 
bloody  ablation  of  the  tonsils,  as  the  dangers  of  hsemorrhage  and  diphtheria 
of  the  wound-surface  are  thereby  avoided.  The  smooth,  dense  cicatrix  thus 
produced  offers  a  very  good  protection  against  new  infection. 

In  adults,  or  even  in  half-grown  children  amenable  to  control,  the  reduc- 
tion of  the  tonsil  can  be  gradually  accomplished  without  general  anaesthe- 
sia, the  procedure  extending  over  a  number  of  sittings.  The  throat  is  pen- 
cilled with  a  cocaine  solution  until  local  anaesthesia  is  produced;  then  a  cold 
galvano-caustic  burner  is  introduced.  It  is  placed  against  the  part  to  be 
treated,  the  current  is  turned  on,  and  one  fourth  or  one  third  of  the  ton- 
sillar surface  is  thoroughly  seared.  For  an  liour  or  so,  small  pieces  of  ice 
should  be  swallowed  by  the  patient  to  allay  the  slight  pain.  The  sittings 
can  be  repeated  about  twice  a  week  or  oftener. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  215 

Quincy  sore  throat  (peritonsillitis)  is  a  phlegmonous  process  established 
in  the  tonsil  itself,  or  in  the  loose  connective  tissue  in  which  it  is  imbedded. 
The  tonsil  is  found  enlarged,  projecting  into  the  pharynx,  and  displacing 
forward  the  anterior  pillar  and  velum.  Dysphagia  and  more  or  less  saliva- 
tion Avith  high  fever  are  regularly  present,  and  do  not  terminate  until 
thorougli  evacuation  has  taken  place.  In  most  cases  confluence  of  a  number 
of  small  abscesses  and  simultaneous  evacuation  is  observed.  In  others, 
especially  when  the  tonsil  itself  is  the  seat  of  the  affection,  a  number  of 
abscesses  develop  and  open  one  after  another,  and  retard  recovery  for  a 
week  or  two.  No  local  treatment  short  of  incision  can  effect  a  substantial 
improvement,  and  the  different  gargling  mixtures  are  only  useful  in  clear- 
ing the  throat  and  mouth  of  the  foul,  sticky  slime  aggravating  the  patient's 
sufferings  by  exciting  very  painful  reflex  movements  at  deglutition.  Hot 
salt  water  (one  teaspoonful  to  a  quart,  about  6  : 1,000)  is  the  best,  as  it  is 
the  most  solvent  gargle,  and  can  be  easily  procured.  As  the  exact  location 
of  the  abscess  can  not  be  ascertained  easily  beforehand,  it  is  wise  to  wait 
with  the  incision  until  the  swelling  is  well  developed.  A  digital  examina- 
tion of  the  swollen  region  is  always  advisable,  as  it  is  not  rare  that  the  tip 
of  the  finger  detects  a  pitting  spot  at  which  incision  will  release  pus.  If 
pitting  can  not- be  detected,  an  examination  with  the  tip  of  a  silver  probe 
will  possibly  help  to  ascertain  the  most  painful  spot  corresponding  to  the 
focus  to  be  incised.  The  relative  distribution  of  the  swelling  may  also  serve 
as  a  guide  in  determining  the  seat  of  pus.  Acute  enlargement  of  the  tonsil 
itself  with  diffuse  oedema  of  the  pillars  and  palate  indicates  suppuration 
tuifhin  the  tonsil.  Displacement  of  the  relatively  normal  tonsil  inward  is  a 
sign  of  retro-tonsillar  suppuration.  A  combination  of  both  will  show  the 
worst  association  of  distressing  symptoms. 

Incising  Tonsillar  Abscess. — A  lancet-shaped  pointed  bistoury  is  pro- 
tected with  strips  of  adhesive  plaster  to  within  an  inch  of  its  point  (Fig. 
171),  the  tongue  is  depressed  with  the  left  index-finger,  while  the  right 
hand  thrusts  the  knife  into  the  base  of  the  swelling  through  the  anterior 
pillar  at  the  point         ' 

rection  should  be       -^''*-  I'i'l-— I^ancet-sbaped  bistoury  wrapped  up  in  adhesive  plaster  for 

incisiion  of  tonsillar  abscess, 
rigidly  adhered  to 

on  account  of  the  vicinity  of  the  carotid  artery.  If  the  first  puncture  be 
unsuccessful,  a  second  one  should  be  made  in  another  likely  place,  and,  as 
soon  as  pus  appears,  the  blade  should  be  turned  inward,  that  is,  toward  the 
median  line,  and  should  be  withdrawn,  dilating  the  incision  in  that  direc- 
tion. A  number  of  fibers  belonging  to  the  levator  palati  will  be  thus  divided, 
and  their  retraction  will  create  a  patent  orifice,  favorable  to  good  drainage. 
Retro-2Jharyngeal  phlegmon  is  a  comparatively  rare  suppuration  of  the 
retro-pharyngeal  connective  tissue,  due  to  septic  infection  of  the  glands 
normally  imbedded  in  it.     It  is  mostly  observed  in  small  children.     The 


216  EULES  OF  ASEPTIC  AND  ANTISEPTIC   SURGERY. 

symptoms  are  those  of  retro-pliaryugeal  abscess  from  tuberculous  caries  of 
the  cervical  vertebrte,  but  its  appearance  is  much  more  rapid,  accompanied 
by  high  sejitic  fever  and  more  acute  local  distress,  causing  difhculty  of 
deglutition,  regurgitation  of  food  through  the  nostrils,  and  alarming 
dyspnoea.  The  most  characteristic  symptom  is  the  peculiarly  rigid  attitude 
of  the  head,  vs^hich  is  erect,  and  thrown  back  to  a  certain  extent  at  the  same 
time.  The  voice  is  thick  and  guttural,  as  though  a  voluminous  foreign 
body  were  held  in  the  throat. 

In  some  cases  the  suppuration  extends  to  the  '^  intermuscular  space," 
and  causes  the  appearance  of  a  lateral  external  swelling  behind  the  sterno- 
mastoid  muscle.  The  transverse  diameter  of  the  neck  then  appears  widened. 
Inspection  of  the  pharynx  shows  that  the  posterior  pharyngeal  wall  is  dis- 
placed forward,  is  densely  infiltrated,  and  sometimes  fluctuating. 

Incision  should  be  done  through  the  oral  cavity  if  the  inflammation  is 
confined  to  the  retro-pharyngeal  region,  but  will  be  more  advantageous  if 
done  from  without  and  behind  the  sterno-mastoid  muscle  in  cases  where 
external  swelling  of  the  cervical  region  is  noticeable. 

In  the  first  case,  the  children  should  be  held  as  for  penciling  of  the 
throat,  and  the  person  having  charge  of  the  head  should  be  instructed  to 
throw  it  forward  at  a  given  signal,  so  as  to  favor  the  escape  of  jjus  and 
blood  outward  from  the  oral  cavity,  and  prevent  its  entering  the  larynx. 

If  lateral  swellings  appear,  proper  incision  from  without  will  afford 
efficient  drainage,  and  at  the  same  time  will  help  to  avoid  the  dangers  accru- 
ing from  the  entrance  of  pus  into  the  larynx. 

The  manner  of  incision  is  best  illustrated  by  the  subjoined  cases. 

Of  a  large  number  of  cases  treated  at  the  German  Dispensary,  and  a  few 
seen  at  consultations  in  private  practice,  only  two  have  terminated  fatally, 
and  in  both  serious  haemorrhage  occurred  a  few  hours  after  the  incision. 

Case  I. — S.  P.,  aged  eighteen  months,  seen  May  17,  1883,  with  Dr.  L.  Weiss. 
Retro-pharyngeal  and  submaxillary  abscess  developed  during  the  florid  stage  of  a 
violent  scarlatina  with  diphtheria.  Dysphagia  and  dyspnoea.  Small  lateral  incision 
through  the  skin  and  fascia  parallel  to,  and  behind  the  posterior  margin  of  the  left 
sterno-mastoid  muscle.  Successful  search  for  pus  with  a  stout  hypodermic  needle,  carried 
inward  and  a  little  backward  toward  the  retro-pharyngeal  space.  Insinuation  of  a 
grooved  director  along  the  hollow  needle,  followed  up  by  the  introduction  of  a  small 
pair  of  dressing  forceps,  which  were  withdrawn  half  opened.  Escnpe  of  about  one 
and  a  half  ounce  of  pus  and  introduction  of  a  drainage-tube.  Two  hours  after  incision 
copious  secondary  hfemorrhage  set  in,  and  rapidly  terminated  in  death.  Giving  away 
of  the  wall  of  a  sloughing  vessel  must  be  assumed  to  have  caused  this  issue. 

Case  II. — Henry  W.,  aged  four  and  a  half  months,  a  healthy  child,  developed, 
March  4, 1883,  fever  and  dysphagia,  due  to  the  presence  of  a  number  of  small  abscesses 
situated  in  the  retro-pharyngeal  connective  tissue.  Several  of  these  were  incised  by 
Dr.  A.  Jacobi,  with  apparent  relief  of  short  duration.  New  foci  appearing,  the  incisions 
were  repeated  March  Otii  and  8th.  March  9th. — Dysphagia  became  complete  and 
dyspnoea  alarming.  Althougli  the  incisions  through  the  retro-pharyngeal  space  con- 
tinued to  bleed,  increasing  the  danger  by  the  addition  of  haemorrhage  to  the  other 
symptoms,  the  extension  of  the  process  to  the  connective-tissue  plane  of  the  large 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  217 

vessels  ami  tlie  rtlunuing  dyspnoea  left  no  alternative  but  death  from  suffocation  or  an 
incision  of  tiie  abscess  from  without.  March  9th,  at  2  P.  M. — This  was  done,  evacuat- 
ing about  half  an  ounce  of  pus.  A  drainage-tube  was  introduced  into  the  bottom  of  the 
cavity,  and,  to  limit  the  oozing,  a  corapressory  dressing  was  applied.  At  If.  P.  M. — 
Scanty  but  continuous  hamiorrhage  set  in  from  the  drainage-tube.  This  being  removed, 
the  cavity  was  plugged  with  strips  of  iodoformed  gauze,  and  the  bleeding  edges  of  the 
incision  were  seared  with  the  thermo-cautery.  At  8.30  P.  M. — The  child  died  of  acute 
anjemia. 

March  10th. — Post-mortem  examination  by  Dr.  A.  Seibert  in  the  presence  of  Dr. 
L.  Bopp  and  the  author.  On  the  neck,  close  to  the  posterior  edge  of  the  left  sterno- 
mastoid,  a  cutaneous  incision  was  found  one  inch  in  length,  its  edges  marked  by  a 
dark-red,  bloody  infiltration.  A  probe  entered  the  retro-pliaryngeal  space,  where  it 
could  be  felt  with  the  finger  placed  in  the  oral  cavity.  A  skin-flap  being  raised  and 
turned  upward,  a  couple  of  intumesceut,  dark-red  lymph-glands,  situated  near  the  an- 
terior edge  of  the  sterno -mastoid  muscle,  were  exposed.  The  sterno-mastoid  muscle 
was  cut  away  at  its  lower  insertion  and  was  turned  upward.  The  vascular  sheath  was 
opened,  and  the  deep  jugular  vein  and  carotid  artery  were  carefully  examined  and 
found  intact.  A  wall  of  tissue  one  third  of  an  inch  in  thickness  was  found  interposed 
hetween  these  vessels  and  the  track  occupied  by  the  silver  probe.  The  prevertebral 
interspace  was  found  distended  by  a  dark,  massive,  and  soft  clot,  extending  upward  to 
the  base  of  the  cranium,  and  downward  to  the  level  of  the  third  tracheal  cartilage. 
Cervical  vertebrse  normal. 

Doubtless  it  was  a  case  of  hsemophilism. 

(A  case  of  retro-pharyngeal  infiltration,  simulating  the  symptoms  of  abscess,  was 
seen  by  the  author  in  the  German  Hospital,  in  which  acute  infectious  osteomyelitis 
of  the  second  cervical  vertelyra  was  the  cause  of  the  trouble.  Henry  Ludwig,  bartender, 
aged  twenty-one,  February  16,  1885. — High  fever  set  in  with  a  chill  and  stertorous 
hreathing.  The  face  was  slightly  cyanosed  and  the  voice  had  a  thick  sound  character- 
istic of  retro-phavyngeal  swelling.  The  patient  held  his  neck  rigidly,  and  in  moving 
supported  it  by  his  hands.  A  typhoid  condition  prevailed.  The  house  surgeon  of  the 
German  Hospital  made  a  free  incision  into  the  swelling  occupying  the  retro-pharyngeal 
region,  but  no  pus  escaped.  In  spite  of  weight  extension,  sudden  death  occurred,  March 
20th,  from  compression  of  the  medulla.  Post-mortem  examination  revealed  a  far-gone 
destruction  of  the  second,  third,  and  fourth  cervical  vertebra.  The  odontoid  process 
was  detached,  and  had  fatally  compressed  the  medulla.) 

Acute  infectious  osteomyelitis  of  the  loiuer  jaio  occurs  either  in  the  adult 
after  traumatism,  such  as  for  instance  fracture  of  its  entire  thickness  by 
violence,  or  injury  to  the  alveolar  process  caused  by  the  extraction  of  teeth  ; 
or  spontaneously  in  the  adolescent.  The  latter  form  is  quite  frequent,  and 
results  generally  in  more  or  less  extensive  necrosis  and  the  formation  of 
abscess.  Perforation  usually  takes  place  toward  the  oral  cavity,  though  oc- 
casionally invasion  of  the  submaxillary  capsule  or  the  vascular  interspace  is 
observed.  Early  incision  will  allay  pain,  relieve  the  fever,  and  will  prevent 
the  extension  of  suppuration. 

The  treatment  of  necroses  of  the  mandible  was  disposed  of  elsewhere. 

(j8)  Suhmaxillary  and  Parotid  Cynanche. — Both  the  submaxillary  and 
parotid  salivary  glands  are  inclosed  in  complete  and  very  dense  fascial  en- 
velopes. On  account  of  this  anatomical  peculiarity,  and  in  the  case  of  the 
submaxillary  gland,  the  vicinity  of  the  tongue  and  larynx,  purulent  inflam- 


218  RULES  OF  ASEPTIC    AND  ANTISEPTIC  SURGERY. 

matious  of  these  organs  present  some  peculiarly  grave  features  worthy  of 
special  attention. 

Human  saliva  normally  contains  a  chemical  substance  akin  to  the  pto- 
maines or  to  snake  poison,  that,  like  the  latter,  seems  to  play  an  important 
part  in  the  process  of  digestion.  Whether  an  undue  development  of  this 
albuminoid  substance,  or  exclusively  the  direct  absorption  of  septic  matter 
from  the  oral  cavity  is  at  the  bottom  of  the  septic  inflammations  of  the  sali- 
vary glands,  is  not  known — suffice  to  say,  that  occasionally  one  or  the  other 
of  these  glands  becomes  the  seat  of  suppurative  inflammation.  Their  resist- 
ant envelope  leads  to  incarceration  of  ichor  and  pus,  to  the  development  of 
enormous  tension  and  its  deleterious  local  and  general  effects — which  are 
dense  infiltration  and  necrosis  of  the  contiguous  soft  parts,  with  dysphagia 
and  suffocative  attacks,  and  a  highly  septic  fever. 

Sublingual  or  Submaxillar!/  Cynanche  {Ludwig's  Angina). — A  painful, 
deep-seated,  hard  swelling  of  the  submaxillary  region  appears,  and  is  quickly 
followed  by  chills  and  high  fever,  the  swelling  rapidly  increasing  in  extent 
and  hardness,  and  the  skin  over  the  submaxillary  gland  turning  dusky  red. 
As  long  as  the  patient  is  up,  his  head  is  held  rigidly  in  one  position,  the 
eyes  moving  in  wide  circles  if  he  wants  to  see  an  object  out  of  his  range  of 
vision.  Or,  if  he  be  unsuccessful,  the  entire  body  is  turned  round  slowly 
to  bring  the  desired  object  within  sight.  The  mouth  is  held  slightly  open, 
the  tongue  is  dry,  the  floor  of  the  mouth  somewhat  oedematous.  Speech  is 
difficult,  as  can  be  seen  from  the  painful  twitchings  of  the  patient's  face 
whenever  he  has  to  say  something.  After  a  while  he  will  seek  the  bed.  The 
face  will  appear  slightly  oedematous  and  cyanosed,  the  eye  has  a  dull  and 
stupid  expression,  the  dry  tongue  is  found  lolling  out  of  the  mouth,  and 
saliva  escaping  alongside  of  it.  The  floor  of  the  mouth  is  very  oedematous, 
and  by  this  time  the  entire  submaxillary  region  will  have  become  swollen 
and  as  hard  as  a  board.  The  labored  snoring  respiration  of  the  patient  gives 
warning  of  the  extension  of  the  oedema  to  the  soft  palate,  fauces,  and  the 
vicinity  of  the  larynx.  The  temperature  indicates  very  high  fever,  and  the 
patient  is  unable  to  allay  his  burning  thirst,  as  swallowing  will  have  become 
impossible.  At  this  stage  oedema  of  the  glottis  may  cause  asphyxia  in  some 
cases,  requiring  immediate  tracheotomy.  In  other  cases  extensive  slough- 
ing of  the  involved  parts  of  the  neck  will  supervene,  and  fatal  hsemorrhage 
may  be  caused  by  erosion  of  large  vessels.  The  grave  sejjticaemia  alone,  or 
the  extension  of  septic  thrombosis  to  the  cranium  or  right  auricle,  may  end 
in  death. 

All  dilatory  measures,  such  as  hot  or  cold  applications,  will  be  useless, 
or  positively  injurious,  and  the  patient's  salvation  depends  on  a  quick 
appreciation  of  the  true  character  of  the  trouble,  followed  by  promj)t  and 
energetic  action. 

Case  I. — It  was  observed  by  the  author  during  bis  military  service  in  Garrison  Hos- 
pital No.  2  at  Vienna,  Austria,  in  November,  1872.  During  convalescence  from  a  severe 
form  of  typhoid  fever,  symptoms  of  sublingual  cynanche  a])peared  in  a  young  soldier 
treated  in  the  division  for  internal  diseases.     Fomentations  being  employed,  tiie  swell- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  219 

ing  assumed  alarming  proportions.  Suddenly  oedema  of  the  glottis  appeared,  and  tlje 
case  was  transferred  to  the  surgical  division.  The  left  side  and  frontal  region  of  the 
neck  were  found  densely  infiltrated  and  very  hard,  and  tracheotomy  had  to  be  per- 
formed under  unusual  difficulties  by  regimental  surgeon  Dr.  Fillenbaum.  A  number 
of  abscesses  were  encountered,  and  purulent  perichondritis  was  found  to  be  the  immedi- 
ate cause  of  the  ojdema  of  the  glottis.  Tracheotomy  relieved  the  dyspnf^a,  but  the 
patient  died  soon  afterward  of  septicaamia. 

Oa.se  II. — Jacob  H.,  farmer,  aged  twenty-one,  admitted  to  the  German  Hospital 
January  19,  1886,  presented  a  circumscribed  red  swelling  of  the  left  submaxillary 
region,  that  had  appeared  with  high  fever  two  days  before  admission.  Face  cyanosed, 
expression  dull,  breathing  stertorous ;  the  mouth  half  open,  tongue  protruding,  floor  of 
mouth  oedematous.  Temperature,  104*5°  Fahr.  Immediate  incision  according  to  Hil- 
ton-Roser's  method  in  anaesthesia.  About  half  an  ounce  of  thin  ichorous  pus  escaped. 
The  incision  was  enlarged  with  a  probe-pointed  knife,  and  drainage  and  a  moist  dress- 
ing were  applied.  In  the  night  a  short  suffocative  attack  appeared.  January  20th. — 
Temperature,  101°  Fahr.  Cyanosis  and  oedema  of  the  floor  of  mouth  appreciably 
diminished.  Improvement  continued,  no  necrosis  following,  and  patient  was  discharged 
cured  February  6th. 

Case  III. — William  B.,  clerk,  aged  twenty-two.  Sublingual  cynanche,  character- 
ized by  protrusion  of  tongue  and  very  high  fever.  The  family  attendant  had  treated 
the  case  for  ten  days  by  poulticing,  and  April  3,  1884,  had  incised  the  swelling  in  the 
submaxillary  region.  Eelief  followed,  but  in  the  night  alarming  dyspnoea,  due  to  arte- 
rial haemorrhage,  supervened,  that  rapidly  distended  all  the  interspaces  of  the  left  side 
of  the  neck,  and  threatened  suffocation.  April  5th. — Early  in  the  morning  trache- 
otomy was  hastily  performed  by  the  author,  who  found  the  left  side  of  the  neck  enor- 
mously swollen,  and  some  bloody  serum  oozing  out  of  the  small  external  incision  and 
from  the  oral  cavity.  The  source  of  the  latter  bleeding  was  found  in  a  sloughy  per- 
foration of  the  floor  of  the  mouth.  As  haemorrhage  had  ceased,  only  a  drainage-tube 
was  placed  into  the  external  incision,  and  a  moist  dressing  was  applied.  The  patient 
was  doing  well  April  7th,  when  he  was  seen  by  the  author  the  last  time.  Later  cm, 
the  family  attendant  informed  the  author  that  another  external  haemorrhage  had 
occurred  during  the  process  of  detachment  of  the  numerous  sloughs,  requiring  deliga- 
tion  of  a  spurting,  probably  the  facial,  artery.     Patient  recovered 

Case  IV. — C.  S.,  watchman,  aged  thirty-two.  Sublingual  cynanche  of  thirty-six 
hours'  standing.  Extensive  hard  infiltration  of  anterior  and  left  side  of  neck.  Dys- 
phagia, dyspnoea,  tongue  protruding.  May  5,  1886. — Incision  by  preparation  at  Ger- 
man Hospital.  The  thickened  capsule  of  the  submaxillary  gland  being  divided,  a  small 
cavity  containing  about  a  half  drachm  of  ichorous  pus  and  debris  was  exposed  and 
drained.  It  just  admitted  the  tip  of  the  index-finger.  Immediate  improvement  of  all 
symptoms.     Patient  was  discharged  cured  May  20th. 

Parotid  Cynanche. — This  may  develop  independently  or  complicated 
with  orchitis  during  and  after  acute  infectious  diseases,  such  as  typhoid  and 
scarlet  fever,  small-pox,  or  the  measles,  or  may  be  the  direct  continuation  of 
an  attack  of  mumps.  It  is  not  as  alarming  in  rapidity  of  development  as 
the  sublingual  form,  but  is  apt  to  be  much  more  tedious  on  account  of  the 
gradual  breakdown  of  the  lobulafced  structure  of  the  parotid  gland.  One 
lobe  after  another  succumbs  to  the  suppurative  process,  and  an  intermina- 
ble series  of  abscesses  make  their  appearance.  Generally  perforation  out- 
ward is  the  rule  ;  occasionally,  however,  perforation  into  the  spheno-max- 


220  RULES   OF   ASEPTIC  AND  ANTISEPTIC  SURGERY. 

illary  fossa,  and  extension  into  the  intermuscular  planes  of  the  neck,  with 
all  its  dangers,  ensues.  Necrosis  of  the  interlobular  septa  is  a  common 
occurrence.  On  account  of  the  necessity  of  avoiding  the  temporal  artery 
and  facial  nerve,  long  incisions  are  impracticable.  They  must  be  small, 
and  several  should  be  made  to  afford  sufficient  drainage. 

Case. — H.  S.,  merchant,  aged  fifty,  ooniTrienced  to  suffer  about  Christmas,  1885, 
from  a  furuncle  of  the  external  meatus.  This  led  to  suppuration  of  the  lymphatic 
gland  normally  found  in  front  of  the  meatus,  and,  under  a  poulticing  treatment,  to 
an  involvement  of  the  parotid  gland.  The  patient  w^as  seen  by  the  author  January 
11,  1886,  and  exhibited  a  large,  non-fluctuating,  very  dense  swelling  of  the  right 
parotid  region,  with  a  temperature  of  104°  Fahr.  His  right  eye  could  not  be  closed 
entirely  (paresis  of  the  facial  nerve),  and  he  was  unable  to  separate  the  jaws  to  the 
slightest  extent.  Besides,  repeated  chills,  sleeplessness,  and  the  intense  pain  radi- 
ating to  the  diverse  branches  of  the  trigeminal  nerve,  had  demoralized  the  man  com- 
pletely. A  vertical  incision  placed  just  in  front  of  the  external  meatus  by  careful 
preparation  released  a  large  mass  of  pus.  The  relief  was  very  great,  and  the  patient 
left  the  house  five  days  later  to  be  treated  at  the  author's  office,  where  he  repaired 
daily  for  many  weeks  longer,  as  the  involvement  and  breaking  down  of  new  lobules 
of  the  parotid  gland  made  frequent  irrigation  and  constant  drainage  a  necessity.  He 
was  discharged  cured  March  28th.  By  October  the  paresis  of  the  orbicularis  palpe- 
brarum had  disappeared. 

(y)  Acute  Glandular  Abscesses  of  the  A?iterior  and  Lateral  Cervical 
Begions. — They  are  caused  by  absorption  of  active  micro-organisms  depend- 
ent on  inflammatory  processes  of  the  oral  and  nasal  cavities,  the  pharynx, 
larynx,  the  lower  jaw,  and  the  mastoid  region.  They  have  to  be  well  dis- 
tinguished from  cold  or  chronic  abscesses  of  the  same  region.  Their  onset 
is  sudden  ;  pain  and  fever  rapidly  develop,  with  deep-seated  dense  infiltra- 
tion, and  gradually  the  corresponding  side  of  the  neck  becomes  cedematous. 
Inflammations  in  the  oral  cavity,  the  tongue,  the  larynx,  and  the  lower  jaw 
produce  an  involvement  of  the  glands  in  the  i^erivascular  space.  They  can 
be  felt  somewhat  in  front  of  the  sterno-mastoid  muscle,  extending  upward 
toward  the  angle  of  the  jaw,  and  are  commonly  known  as  ''submaxillary" 
glands.  Affections  of  the  temporal,  auricular,  and  mastoid  regions,  and  of 
the  pharynx,  nasal  cavity,  and  oesophagus,  on  the  other  hand,  are  generally 
followed  by  intumescence  or  suppuration  of  the  glands  situated  in  the  in- 
termuscular space.  They  can  be  felt  behind  the  posterior  margin  of  the 
sterno-mastoid,  and  their  suppuration  is  apt  to  extend  in  the  direction  of 
the  supraclavicular  space. 

The  question  of  when  to  incise  these  abscesses  should  not  be  made  de- 
pendent upon  the  presence  of  fluctuation,  as  the  worst  and  most  virulent 
cases  will  have  wrought  infinite  mischief  long  before  the  appearance  of 
fluctuation.  In  very  virulent  cases,  marked  by  violent  general  symptoms 
and  rapid  local  spread,  incision  should  be  made  at  once  after  Hilton-Eoser's 
method,  as  relief  from  tension  is  the  most  urgent  requisite  to  prevent  slough- 
ing and  possible  erosion  of  vessels.     Anaesthesia  is  indispensable. 

Where  the  symptoms  are  less  violent,  the  spread  less  rapid,  maturing  of 
the  abscess  may  be  awaited  in  case  the  patients  are  very  averse  to  an  incision. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  221 

But  the  responsibility  for  the  consequences  of  delay  should  be  declined  by 
the  physician. 

Case. — Louis  Lebowitsch,  aged  twenty-seven,  presser.  December  15^  188<i. — Pain- 
ful hard  swellings  developed  in  the  pretracheal  and  both  submaxillary  regions  with  a 
severe  chill.  Previous  to  this  the  patient  had  been  suffering  from  a  "  sore  throat "  for 
a  few  days.  The  family  physician  advised  poulticing,  which,  as  usual,  was  enthusiasti- 
cally attended  to  by  the  patient's  female  relatives.  The  swellings  continued  to  grow  in 
size;  fever  and  sleeplessness  were  unabated.  December  i25th. — Suddenly  an  enormous 
increase  of  the  swellings  in  front  and  on  the  left  side  occurred,  with  dyspnoea  and 
dysphagia,  which  induced,  December  29th,  the  patient's  transfer  to  Mount  Sinai  Hos- 
pital. Following  a  hasty  summons  the  author  found  the  patient  sitting  up  in  bed,  his 
head  held  erect,  the  neck  increased  to  double  its  circumference,  its  skin  red,  swollen, 
and  shining  like  a  large-sized  sausage.  Boggy  fluctuation  everywhere.  Most  intense 
thirst  with  absolute  disability  to  swallow  even  fluids ;  wheezing,  long-drawn  respira- 
tion with  considerable  dyspnoea,  which  became  augmented  to  an  alarming  degree  by 
the  reclining  posture.  Examination  of  the  fauces  revealed  a  swelling  of  the  retro- 
faucial  soft  tissues,  and  almost  complete  contact  of  the  slightly  intumescent  tonsils. 
Two  incisions,  one  behind  the  posterior  margin  of  tbe  sterno-mastoid  muscle,  the  other 
a  little  below  the  thyroid  gland,  released  about  a  quart  of  a  dark-red  gory  liquid,  streaked 
with  pus.  This  was  followed  by  an  immediate  disappearance  of  the  dyspnoea,  and  tlie 
patient  was  abl§  at  once  to  allay  his  thirst  by  copious  drafts  of  water.  A  digital  ex- 
amination of  the  cavities  opened  by  the  incisions  showed  them  to  communicate  freely. 
The  pulsating  carotid  could  be  distinctly  felt,  lying  exposed  behind  a  large,  roundish 
mass  of  blood-clot,  freely  projecting  into  the  lateral  cavity,  and  seemingly  attached  to 
the  pharyngeal  wall. 

Two  stout  drainage-tubes  were  placed  in  the  incisions,  the  remaining  clots  were 
washed  out  by  gentle  irrigation,  and  a  large,  moist  dressing  was  applied.  The  fever 
fell  at  once  from  103°  Fahr.  to  100°  Fahr.,  but  rose  the  following  day  to  103°  Fahr., 
as  the  incisions  were  clearly  insufficient  for  the  drainage  of  the  enormous  cavity.  More- 
over, there  was  still  considerable  oozing  present,  and  therefore  it  was  deemed  proper 
to  anaesthetize  the  patient  again,  for  the  sake  of  a  thorough  exploration,  drainage,  and 
possibly  prevention  of  further  hfemorrhage.  A  fluctuating  place  just  above  the  clavicle 
was  incised,  and  was  found  communicating  by  a  narrow  channel  with  the  upper  cavity. 
Both  of  the  lateral  incisions  were  now  united  by  preparation,  the  external  jugular  vein 
being  first  secured  by  double  ligature  and  divided,  and  thus  by  this  long  incision  the 
interior  of  the  large  abscess  was  exposed  to  view.  The  cavity  extended  from  the 
clavicle  to  the  base  of  the  cranium.  In  it  lay  exposed  the  carotid  artery  and  the  jugu- 
lar vein,  to  the  upper  portion  of  which  anteriorly  a  large,  firm,  and  irregular  clot  was 
found  adhering,  indicating  where  the  hsemorrhage  had  come  from.  The  loose  clots 
were  all  cleared  out,  but  the  one  adherent  to  the  jugular  was  left  undisturbed.  Copi- 
ous oozing  from  the  abscess  walls  was  observed,  and  checked  by  a  loose  packing  of 
iodoformed  gauze,  preceded  by  thorough  irrigation.  The  patient  was  discharged 
cured  on  January  2Y,  1887. 

The  preceding  case  vividly  illustrates  the  dangers  of  protracted  poultic- 
ing in  deep-seated  lymphatic  abscesses.  Sloughing  of  the  wall  of  an  adja- 
cent large  vein  caused  a  most  serious  complication  by  secondary  haemorrhage. 
Arterial  haemorrhage  would  have  undoubtedly  produced  rapid  suffocation, 

(8)  Glandular  Abscesses  of  the  Temporal,  Mastoid,  and  Occipital  Re- 
gions.— Suppurative  processes  located  in  the  external  ear  will  occasionally 
30 


222  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

extend  to  one  or  more  lymphatic  glands,  subfascially  situated  in  front  of 
the  external  meatus  of  the  ear,  and  in  close  vicinity  to  the  parotid  gland. 
They  produce  very  violent  general  and  local  symptoms,  and  require  early 
attention,  as  a  subsequent  involvement  of  the  parotid  gland  is  very  apt  to 
occur. 

Suppuration  of  the  mastoid  cells  is  the  most  common  form  of  extension 
of  a  purulent  otitis  of  the  external  or  middle  ear.  Its  symptoms  bear  great 
resemblance  to  those  of  acute  osteomyelitis,  and  require  prompt  attention  on 
account  of  the  possibility  of  necrosis  and  the  involvement  of  the  meninges, 
brain,  or  lateral  sinus.  Where  intense  swelling  indicates  the  presence  of 
purulent  periostitis  of  the  mastoid  process,  a  free  incision  of  all  the  soft  parts 
down  to  the  bone  will  often  give  great  relief.  But,  where  the  interior  of  the 
cancellous  structure  of  the  mastoid  process  is  the  seat  of  the  disease,  noth- 
ing short  of  a  free  opening  of  its  interior  will  avail.  Formerly,  this  opera- 
tion was  done  with  the  aid  of  the  trephine,  an  instrument  the  penetration 
of  which  is  somewhat  beyond  the  supervising  control  of  the  surgeon.  At 
present  mallet  and  chisel  are  used  for  this  purpose  with  greater  advantage. 
The  chisel  should  be  held  tangentially  to  the  external  surface  of  the  mastoid 
process,  thin  layers  of  bone  being  pared  off  in  succession,  until  the  suppurat- 
ing focus  is  freely  exposed.  Thus  injury  to  the  lateral  sinus  can  be  safely 
avoided.  Copious  irrigation  with  a  loarm  solution  of  corrosive  sublimate 
and  a  moist  dressing  are  advisable.  The  cases  in  which  early  operating  has 
prevented  necrosis  will  heal  very  promptly.  Necrosis  will  retard  the  cure 
considerably,  and  may  require  a  second  or  even  a  third  operation  for  the 
removal  of  sequestra. 

In  neglected  cases  spontaneous  perforation  through  the  periosteum  will 
occur,  and  an  external  abscess,  located  posteriorly  to  the  sterno-mastoid 
muscle,  will  appear.  The  tendency  of  its  extension  is  toward  the  "inter- 
muscular space,"  that  is,  downward  into  the  supraclavicular  fossa. 

Occasionally  the  process  extends  backward  and  upward  upon  the 
occiput. 

Case  I. — Fred.  Buths,  baker,  aged  eighteen,  admitted  to  ear  department  of  German 
Hospital,  December  17,  1883,  with  purulent  catarrh  of  the  middle  ear  and  suppuration 
of  mastoid  cells.  Wilde's  incision  and  extraction  of  some  sequestra  from  the  external 
meatus  were  practiced  by  Dr.  J.  Sirarock.  A  phlegmon  of  the  left  occipital  region, 
starting  from  a  sinus  below  the  mastoid  process,  having  set  in,  patient  was  transferred, 
March  25,  1884,  to  the  surgical  department.  March  26th. — High  fever  and  violent 
headache  with  vomiting.  Several  incisions  laid  open  an  irregular  cavity  situated  be- 
hind the  ear  and  extending  downward  toward  the  neck.  On  pressure,  a  large  quantity 
of  pus  oozed  out  of  a  recess  between  exuberant  granulations  near  the  lower  anterior 
angle  of  the  parietal  bone.  These  being  scraped  away,  a  sequestrum,  about  one  square 
inch  in  circumference,  and  comprising  the  whole  thickness  of  the  skull,  was  extracted. 
Pulsation  of  the  bottom  of  the  cavity  thus  exposed  was  clearly  discernible.  Healing 
progressed  without  Interruption,  the  purulent  discharge  from  the  middle  ear  ceased, 
and  patient  was  discharged  cured,  April  17,  1884,  with  a  deeply  indented  scar.  In 
October,  1880,  he  presented  himself,  complaining  of  epilei)tic  seizures  that  had  appeared 
in  July,  1 880. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  223 

Case  II. — E.  N.,  merchant,  aged  twenty-five.  Had  been  suffering  from  purulent 
otitis  media  for  a  long  time.  Suppuration  of  the  mastoid  cells,  and  formation  of  an 
external  inframastoidal  abscess,  led  to  incision,  which  was  done  by  Dr.  E.  Gruening, 
under  whose  care  the  patient  had  been  for  some  time.  A  phlegmonous  inflammation 
of  the  neck  following,  January  22,  1882,  a  consultation  was  called,  when  a  number 
of  deep  incisions  back  of  the  sterno-mastoid  muscle  were  made,  and  the  abscesses  were 
drained.  The  probe  felt  bare  bone  in  the  mastoid  notch.  Subsequently  a  considerable 
quantity  of  bony  grits  passed  away  with  the  secretions,  and  the  carbolic  lotion  injected 
into  the  drainage-tubes  entered  the  oral  cavity.  End  of  March,  the  patient  was  dis- 
charged cured,  and  remained  well  until  September,  1886,  when  he  was  seen  by  the 
author  suffering  from  dementia. 

l.  Mammary  and  Retro-mammary  Abscess. — Excoriations  and  fissures,  so 
common  upon  the  nipples  of  nursing  women,  are  the  portals  through  which 
infection  enters  the  multitudinous  lymphatics  of  the  mammary  gland.  A 
preparatory  treatment  of  the  nipples  during  the  last  period  of  pregnancy  is 
the  best  preventive  of  the  formation  of  fissures.  It  should  consist  in  molli- 
fying, and  removal  by  bathing  in  warm  soap-water,  of  the  thick  layers  of 
effete  epidermis,  usually  present  around  the  openings  of  the  lacteal  ducts. 
The  tender  epidermis  thus  exposed  will  be  hardened,  and  will  become  fit  to 
resist  the  manifold  injuries  unavoidable  during  lactation. 

Should  rhagades  develop,  a  thorough  disinfection  with  corrosive-subli- 
mate lotion  (1  : 1,000),  followed  by  touching  of  the  fissures  with  a  well- 
sharpened  stick  of  nitrate  of  silver,  will  in  most  cases  lead  to  a  cure  of  the 
painful  disorder.  Nursing  should  be  either  stopped  and  the  milk  removed 
with  the  breast-pump,  or,  if  continued,  should  be  only  permitted  with  a 
nipple-shield,  until  the  fissure  is  closed. 

Disregard  of  these  precautions  will  frequently  lead  to  suppuration. 

A  large  proportion  of  the  inflammatory  processes  of  the  breast  are  non- 
suppurative, the  intumescence,  redness,  and  occasionally  smart  fever  being 
set  up  by  a  retention  of  the  thickish  milk  of  first  lactation.  Sometimes 
fluctuation  will  be  felt,  and,  if  an  incision  is  made,  no  pus — only  milk — will 
escape.  Absence  of  an  infection  by  micro-organisms  must  be  assumed  in 
these  cases,  which,  as  a  rule,  get  well  without  suppuration  by  simple  topical 
treatment,  consisting  of  the  application  o£  moist  heat  and  methodical  com- 
pression. 

Hence,  not  all  cases  of  acute  mastitis  terminate  in  abscess.  AVinckel 
saw,  in  the  Dresden  Lying-in  Hospital,  ninety-one  out  of  a  total  of  one 
hundred  and  thirty-six  cases  of  mastitis  get  well  without  suppuration. 
Therefore,  topical  treatment  with  the  ice-bag  or  cold-water  coil  (by  both  of 
these  the  secretion  of  milk  is  materially  reduced),  or,  if  opposition  to  these 
be  encountered,  tepid  or  warm  applications,  aided  by  support  and  gentle 
compression  of  the  breast,  should  be  first  tried. 

Should,  however,  fever  and  the  local  symptoms  persist  or  increase,  and 
fluctuation  become  apparent,  incision  and  drainage  are  the  measures  to  be 
applied. 

Abscesses  of  the  mammary  gland  proper  are  either  subcutaneous,  then 
generally  located  about  the  nipple ;  or  are  more  deep-seated,  that  is,  intra- 


224:  RULES   OF  ASEPTIC   AND  ANTISEPTIC  SURGEEY. 

(llanduJar.  A  third  form  of  breast  abscess  is  the  suppuration  of  the  loose 
counective  tissue  found  behind  the  gUind  :  retro-manimary  abscess. 

Its  location  in  the  vicinity  of  the  nipple  and  the  early  appearance  of 
well-detined  fluctuation  will  readily  characterize  the  subcutaneous  abscess. 

When  the  deeper  parts  of  the  glandular  tissue  proper  become  the  seat  of 
an  abscess,  general  swelling  of  the  breast-gland  is  most  prominent.  The 
skin  of  the  mamma  becomes  red  and  oedematous,  and  one  or  more  pitting 
points  can  be  soon  detected.  Btit  the  breast  is  freely  movable  as  a  whole 
upon  the  pectoralis  fascia. 

In  retro-mammary  suppuration  the  breast  is  immovable,  and  firmly 
attached  at  its  base.  The  glandular  tissue  is  soft  and  normal,  unless  a 
combination  of  mammary  and  retro-mammary  suppuration  be  present. 
Deep  fluctuation  can  be  detected  by  careful  palpation. 

Incision  of  the  more  extensive  abscesses  of  the  breast  should  alivays  be 
done  under  ancesthesia,  as  the  unavoidable  pain  associated  with  thorough 
work  is  too  great  to  be  endured  ;  and  the  measures  must  be  thorough  to 
give  a  prompt  result,  as  nothing  is  more  vm satisfactory  than  an  insufficient 
or  improperly  placed  incision.  Suppuration  is  not  limited  thereby,  new 
points  of  fluctuation  develop,  and  the  interminable  process,  with  fever,  sleep- 
lessness, and  the  drain  upon  the  system,  lead  to  serious  emaciation  and 
lamentable  demoralization  of  both  patient  and  physician.  Antiseptic  pre- 
cautions, consisting  of  a  thorough  scrubbing  of  the  surgeon's  hands  and  of 
the  patient's  breast  with  soap  and  brush,  and  subsequent  rubbing  off  with 
corrosive-sublimate  lotion  (1  : 1,000),  should  never  be  neglected.  There  are 
microbial  cultures  of  various  intensity  of  virulence,  and  the  touch  of  an 
unclean  finger  may  intensify  an  otherwise  comparatively  bland  form  of  sup- 
puration, or  may  add  the  poison  of  erysipelas  to  that  of  simple  suppuration. 

All  incisions  penetrating  the  glandular  tissue  should  be  placed  radially, 
so  as  to  avoid  injury  to  the  lacteal  ducts  as  much  as  possible. 

A  place  of  fluctuation  being  marked,  the  knife  is  rapidly  thrust  into  the 
abscess,  if  the  thickness  of  tissues  to  be  cut  through  is  not  too  great.  In 
the  latter  case,  Hilton-Eoser's  method  is  safer  and  preferable,  on  account  of 
the  possibility  of  haemorrhage  from  a  deep-seated  vessel. 

Note. — Billroth  recounts  a  case  in  which  he  caused  uncontrollable  and  very  serious  haemor- 
rhage by  cutting  a  large  branch  of  the  external  mammary  artery.  The  loss  of  blood  was  alarm- 
ing, and  so  beyond  control  that,  after  having  unsuccessfully  tried  a  number  of  the  usual  measures, 
he  finally  injected  the  abscess  cavity  with  a  quantity  of  turpentine  oil,  that  happened  to  be 
within  reach.  The  bleeding  was  stopped,  but  a  formidable  gangrenous  phlegmon  brought  the 
patient  very  near  the  grave.     She  recovered,  however. 

As  soon  as  the  well-dilated  dressing  forceps  is  withdrawn,  the  index  of  the 
left  hand  is  slipped  into  the  cavity,  and  a  gentle  exploration  of  its  interior  is 
carefully  made.  Wherever  a  recess  extends  toward  the  skin,  the  tissues  are 
rai.sed  upon  the  tip  of  the  left  index-finger,  the  skin  and  fascia  are  incised, 
and  the  dressing  forceps  is  introduced  along  the  grooved  director  in  the  well- 
known  manner.  In  this  way  a  number  of  short  counter-incisions  can  be  made 
with  very  little  haemorrhage.     8tout  drainage-tubes,  reaching  just  within 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  225 

the  cavity,  are  next  introduced,  and  tlie  abscess  is  well  washed  out  with  the 
mercuric  lotion.  Oozing  from  the  abscess  walls,  which  is  sometimes  con- 
siderable, will  also  be  cbecked  thereby.  After  this  the  breast  should  be 
grasped  and  gently  compressed  between  the  extended  hands  as  a  test, 
whelJier  all  recesses  had  been  duly  em-ptied  or  not.  The  appearance  of 
additional  masses  of  pus  will  be  a  proof  that  something  was  overlooked, 
and  renewed  search  must  be  instituted  to  find  and  drain  the  overlooked 
recess. 

Note  and  Case. — The  observance  of  this  simple  rule  led  to  the  recognition  of  a  very  interesting 
and  rare  form  of  suppurative  mastitis.  Mrs.  C.  F.,  primipara,  admitted  to  Mount  Sinai  Hospital 
two  weeks  after  her  confinement,  with  abscess  of  the  breast.  Had  very  little  fever.  She  was  anaesthe- 
tized December  20, 1886,  and,  four  fluctuating  spots  situated  just  above  and  near  the  nipple  being 
incised,  the  finger  was  slipped  into  one  of  the  incisions,  and  found  the  irregular  and  tortuous 
cavities  communicating  with  each  other.  A  large  number  of  smaller  cavities  occupying  the 
upper  half  of  the  mammary  gland  were  entered,  and  the  intervening  bridges  of  tissue  were 
broken  down  with  the  finger.  Haemorrhage  was  very  scanty.  The  cavity  was  washed  out,  and, 
gentle  pressure  being  applied,  an  additional  large  mass  of  thick  pus  escaped.  A  long  incision 
uniting  the  two  most  distant  primary  incisions,  and  passing  through  the  entire  width  of  the  gland, 
was  now  made.  It  exposed  the  cavity,  which  was  found  lined  with  necrosed  shreds  of  glandu- 
lar tissue.  The  abscess  walls  exuded  on  firm  pressure  from  hundreds  of  invisible  openings 
separate  drops  of  creamy  pus.  A  portion  of  the  indurated  wall  of  the  cavity  was  pared  off, 
until  seemingly  healthy  tissue  was  encountered.  Firm  pressure  being  repeated,  the  same  exuda- 
tion of  pus  from  innumerable  pores  of  the  cut  surface  was  observed.  The  section  had  a  deep- 
yellow  tinge,  and  presented  the  density  of  fibromatous  tissue.  The  lower  half  of  the  breast-gland 
was  normal  and  secreted  milk.  An  iodoform  dressing  was  applied,  and  remained  undisturbed 
until  December  S'Zth,  when  the  patient  complained  of  pain  and  exhibited  some  fever.  The 
dressings  being  removed,  a  new  abscess  was  found  and  incised  near  the  upper  margin  of  the 
long  incision.  The  old  abscess  cavity  was  granulating,  but  its  walls  still  exhibited  the  peculiar 
appearance  of  a  large  number  of  distinct  pus-drops  on  pressure.  The  wretched  general  con- 
dition of  the  patient,  and  the  presumably  interminable  suppuration  to  be  expected  under  the 
circumstances  suggested  exsection  of  the  aifected  parts  of  the  breast  as  the  most  rational 
measure.  This  step,  however,  was  strenuously  opposed  by  the  patient,  and  she  left  the  hospital 
uncured. 

Apparently  we  had  in  this  case  a  form  of  purulent  mastitis  where  the 
suppurative  process  was  primarily  located  in  the  lacteal  ducts,  the  intersti- 
tial connective  tissue  assuming  the  character  of  shrinking  fibroid  or  cica- 
tricial tissue,  as  in  non-suppurating  interstitial  mastitis.  The  contraction  of 
the  interstitial  tissue  led  to  closure  of  the  lacteal  ducts  and  to  retention ; 
this  to  perforation  of  the  lacteal  ducts  and  extension  of  the  suppuration  into 
the  interstitial  tissue  ;  this,  finally,  to  the  formation  of  a  large  number  of 
disseminated  abscesses  and  necrosis.  Throughout,  the  case  exhibited  un- 
usual characteristics  :  well-circumscribed  localization,  low  fever  with  appall- 
ing destruction  of  tissues,  and  their  curious  permeation  with  canals,  that 
could  be  nothing  but  lacteal  ducts,  filled  with  creamy  pus.  As  drainage 
and  disinfection  of  the  infected  lacteal  ducts  were  impossible,  ablation  of  the 
diseased  part  of  the  gland  was  clearly  the  proper  way  to  terminate  the 
process. 

Retro-mammary  abscesses  usually  point  near  the  lower  margin  of  the 
breast-gland.     They  should  be  treated  like  other  deep-seated  abscesses,  by 


226 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


incision  and  drainage,  care  being  taken  to  establisli  the  latter  in  the  most 
dependent  position. 

When  the  operation  is  comjileted,  safety-pins  are  thrust  tlirongli  the  pro- 
jecting ends  of  the  drainage-tubes  near  the  surface  of  the  skin,  and  they  are 
trimmed  off  sliort.  A  small  ring  of  iodoformed  gauze  is  placed  underneath 
the  safety-pin  around  the  drainage-tube,  to  prevent  its  being  overlapped  by 
the  edges  of  the  wound,  and  a  moist  antiseptic  dressing  is  applied.  In  the 
absence  of  fever  and  pain,  and  if  the  dressings  remain  unpermeated  by  secre- 
tions, they  need  not  be  changed  before  three  or  four  days,  when  the  drain- 
age-tubes can  be  either  wholly  removed,  or  one,  having  previously  been 
somewhat  shortened,  can 
be  left  in  the  most  de- 
pendent incision  till  the 
following  change  of  dress- 
ings. 

Where  shreds  of  ne- 
crosed tissue  are  still  ad- 
herent to  the  walls  of  the 
abscess,  secretion  will  be 
somewhat  more  copious, 
and  permeation  of  the  dressings 
will  require  daily  changes  until 
the  necrosed  parts  come  away. 
During  this  time,  however,  if 
drainage  be  adequate,  all  the  pus 
secreted  sliould  he  contained  in  the 
dressings,  and  none  in  the  luound.  After  detachment  of  the  necrosed  parts, 
secretion  will  become  scanty  and  watery  in  character,  and  removal  of  the 
tubes  will  be  followed  by  rapid  closure  of  the  wound. 

In  cases  where  drainage  is  inadequate,  fever  and  pain  will  persist,  and 
secretion  will  remain  profuse.  The  dressings  will  need  frequent  renewal, 
they  will  be  rapidly  soaked  with  pus,  and  the  wound  itself  will  contain 
more  or  less  of  it.  This  can  be  easily  ascertained  by  gentle  pressure,  which 
will  cause  a  copious  flow  of  pus.  Frequent  irrigation  is  a  very  imperfect 
substitute  of  proper  drainage  ;  therefore,  the  making  of  a  well-placed  incis- 
ion should  remedy  the  shortcoming. 

c.  Empyema. — Infection  of  the  pleura  by  pyogenic  organisms,  either 
through  metastatic  processes  or  by  direct  extension  from  the  bronchi  and 
lungs  ;  from  without  by  injury,  or  from  purulent  affections  of  the  vicinal 
regions,  as,  for  instance,  perinephritic  or  liver  abscess,  leads  to  the  forma- 
tion of  empyema — that  is,  an  accumulation  of  pus  within  the  pleural  cavity. 
The  diagnosis  of  the  affection  is  based  upon  the  fever,  dyspnoea,  the  absence 
of  respiratory  murmur,  the  dull  percussion  sound,  rigidity  of  the  affected 
side  of  the  thorax,  flatness  of  the  intercostal  depressions,  and  more  or  less 
marked  cedema  of  the  integument  over  the  site  of  the  accumulation. 

Probatory  ])iincture  with  a  hypodermic  needle  will  usually  yield  pus. 


Fig.  172.- 


-Dressing  for  mammary  abscess, 
or  empyema. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  227 

The  proper  treatment  consists  of  timely  incision,  disinfection,  and  drain- 
age nnder  antiseptic  cauteh\3. 

Management  of  Recent  Cases  of  Empyema. — The  thorax  of  the  ansesthe- 
tized  patient  is  cleansed  and  disinfected,  and  an  incision  is  made,  from  two 
to  three  inches  in  length,  in  the  eighth  intercostal  space,  parallel  with  the 
ribs,  and  a  little  back  of  the  axillary  line.  The  skin  and  muscles  are  grad- 
ually divided  down  to  the  pleura,  which  is  then  incised.  The  sudden  gush 
of  ])us  is  checked  and  moderated  by  the  pressure  of  the  tip  of  the  finger,  as 
too  sudden  evacuation  of  the  tense  accumulation  may  lead  to  rupture  of  ves- 
sels, or,  in  the  case  of  empyema  of  the  left  pleural  cavity,  to  fatal  embolism 
of  the  pulmonary  artery.  In  these  cases  the  heart  is  displaced  to  the  right 
side,  and  any  clots  that  may  have  formed  within  the  right  auricle  could  be 
easily  detached  by  a  sudden  change  of  the  heart's  position.  This  accident 
has  occurred  once  to  the  author.  However,  it  did  not  take  place  on  the 
operating-table,  but  happened  several  days  after  the  operation. 

Case. — Helen  Muller,  aged  eleven.  Empyema,  with  two  fistulse,  of  six  years' 
standing.  Great  emaciation ;  retention  of  fetid  pus;  the  heart  displaced  to  the  right 
side.  February  27^  1883. — Exsection  of  two  ribs,  multiple  incisions,  and  drainage  of 
the  fetid  abscess.  Daily  irrigation  produced  a  marked  remission  of  the  fever,  and 
everything  seemed  to  progress  favorably,  when,  March  6th,  while  playing  in  bed,  the 
child  suddenly  became  cyanosed,  and  fell  back  dead.  No  post-mortem  examination 
could  be  had.     Death  was  doubtless  caused  by  embolism  of  the  pulmonary  artery. 

The  pleural  incision  should  be  ample,  as  otherwise  voluminous  fibrinous 
pseudo-membranes  may  clog  the  exit  of  pus.  A  large-calibered  drainage- 
tube,  7'eacMng  just  within  the  pleural  sac,  is  inserted,  and  is  at  once  secured 
ivith  a  stout  safety-pin,  to  prevent  its  being  lost  in  the  abscess.  This 
occurred  in  one  case  treated  at  the  German  Hospital,  and  a  good  deal  of 
trouble  was  experienced  in  finding  the  lost  tube. 

Case. — Fridolin  Jaehle,  laborer,  aged  forty-three,  saccated  empyema  of  eight  weeks' 
standing.  February  9,  I884,. — Posterior  incision  in  the  eighth  intercostal  space ;  evacu- 
ation of  a  large  quantity  of  pus.  A  drainage-tube  was  inserted,  but  slipped  out  of  the 
fingers,  and  was  lost  in  the  cavity.  The  incision  was  sufficiently  enlarged  to  admit  two 
fingers,  and  then  a  sort  of  a  diaphragm  could  be  felt  separating  two  intercommunicat- 
ing cavities.  A  counter  incision  was  made  in  the  mammary  line,  and  the  lost  drainage- 
tube  was  extracted  therefrona.  Drainage-tubes  properly  fastened  with  safety-pins  were 
inserted,  and  the  cavity  was  irrigated  with  carbolic  lotion.  Moist  dressings  were  ap- 
plied.    Jpril  18th. — Patient  was  discharged  cured. 

Washing  of  the  pleural  cavity  with  warm  mercuric  solution  (1  :  5,000) 
thrown  from  an  irrigator  should  be  done,  until  the  fluid  returns  in  a  limpid 
state.  Then  a  final  flushing  with  corrosive-sublimate  lotion  of  the  strength 
of  1  :  1,000  should  follow,  and  good  care  should  be  taken  to  drain  off  the 
last  vestige  of  the  solution  by  turning  the  patient  so  as  to  bring  the  incision 
nethermost.  A  very  ample  moist  dressing  should  envelop  the  patient's 
thorax. 

As  long  as  the  temperature  remains  normal  or  slightly  elevated,  and  the 
dressing  clean,  no  change  is  necessary.     Usually,  however,  the  dressings 


228  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

will  be  soiled  within  twenty-four  hours,  and  then  they  must  be  changed. 
But  irrigation  should  not  be  employed  so  long  as  the  patient's  temperature 
is  normal.  Only,  if  renewed  fever  appear,  or  the  secretion  assume  a  fetid 
odor,  will  repetition  of  the  irrigation  be  necessary.  In  fresh  empyemata, 
especially  of  children,  one  irrigation  thorouglily  done  at  the  time  of  the 
operation  ivill  he  found  sufficient.  But  in  some  favorable  cases  of  adults 
the  same  smooth  course  of  healing  may  be  observed.  The  discharges  will 
gradually  diminish,  they  will  lose  their  purulent  character,  and  will  become 
watery  and  scanty.  As  soon  as  this  is  observed,  the  drainage-tube  should 
be  removed,  and  within  four  or  six  weeks  from  the  operation  the  cavity  will 
be  healed  by  renewed  adhesion  of  the  costal  and  pulmonal  pleura.  The 
lung  will  dilate  to  its  normal  extent,  and  the  universal  adhesion  of  the 
pleural  surfaces  will  gradually  give  way  to  constant  attrition,  until  the 
mobility  of  the  lung  and  the  normal  state  of  things  are  re-established. 

Case. — Henry  Fennell,  furniture-dealer,  aged  tliirty.  Empyema  on  left  side  of  four 
weeks'  duration.  February  1,  1880. — Communication  with  a  larger  bronchus  spon- 
taneously established,  giving  rise  to  uncontrollable  fits  of  coughing,  which  have  ex- 
hausted the  patient  to  a  dangerous  degree.  February  6th. — Incision,  drainage,  and 
irrigation  with  a  five-per-cent  solution  of  carbolic  acid.  The  cough  stopped  at  once; 
the  fever  fell  off.  February  17th. — Discharge  very  scanty  and  watery ;  drainage-tubes 
were  removed.  February  19th. — Sudden  rise  of  temperature,  with  chill.  February 
20th. — Pleuritic  serous  effusion  on  right  side.  March  1st. — Effusion  on  right  side  begins 
to  be  absorbed.  Left  lung  dilated  to  nearly  its  normal  compass.  March  6th. — Exuda- 
tion in  right  pleura  has  disappeared.    March  12th. — Patient  was  discharged  cured. 

Lateral  curvature  of  the  spine  is  a  prominent  symptom  of  long-continued 
empyema,  and  is  very  hard  to  cure.  The  moderate  amount  of  lateral  curva- 
ture that  goes  along  with  recent  empyema  disappears  with  the  restoration 
of  the  function  of  the  compressed  lung. 

Old  Empyema. — Cases  of  inveterate  empyema  with  or  ivithout  sinus  throw 
much  greater  difficulties  in  the  way  of  the  surgeon's  efforts  to  close  the  cav- 
ity and  fistula  than  recent  cases.  The  retraction  and  consolidation  of  the 
lung,  and  its  envelopment  in  more  or  less  thick  coats  of  pseudo-membrane, 
frustrate  all  attempts  at  closure  of  the  thoracic  cavity.  The  unyielding- 
lung  can  not  expand,  while  the  contraction  of  the  partially  yielding  walls 
of  the  thorax,  accomplished  by  lateral  curvature,  by  a  close  crowding  to- 
gether of  the  ribs,  and  a  corresponding  flattening  of  the  affected  side  of  the 
chest,  has  its  limits.  Thus  a  secreting  hollow  space  is  maintained  within 
the  chest  that  can  not  be  obliterated  by  the  unaided  efforts  of  nature,  and 
ultimately  the  patient's  strength  and  life  will  be  sapped.  The  injection  of 
irritating  fluids,  or  the  packing  of  the  cavity  with  strips  of  lint  or  gauze, 
are  of  no  avail,  and  the  only  means  of  effecting  a  cure  is  multiple  exsection 
of  the  ribs  according  to  the  plan  of  Estlander. 

The  rationale  of  this  ])lan  is  to  do  away  with  the  rigidity  of  the  thoracic 
wall  by  removing  suitably  long  sections  of  as  many  ribs  as  are  found  to  be 
corresponding  to  the  cavity.  Thus  the  limbered  thoracic  wall  may  be 
depressed,  and  caii  be  brought  into  actual  contact,  or  nearly  so,  with  the 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


221) 


Fig.  173. — Cicatrix  iii  a  eas-e 
of  Estlander's  operation 
for  inveterate  thoracic  fis- 
tula. (John  Springer's 
ease.) 


opposite  or  pulmonal  surface  of  the 
cavity,  where   it  Avill  be   fastened 
down   and   retained    by  cicatricial 
adhesions  that  will  form  before  the 
reconstruction  of  the  exsected  ribs. 
In  due  course  of  time  the  at- 
tached lung  may  even  regain  a  large 
proportion  of  its  former  functional 
capacity  by  distention  and  aeration, 
and  the  more  or  less  comiDlete  re- 
establishment   of   lung   capacity  is 
manifested  by  the  disappearance  of  lateral  curvature. 
Case  I. — John  Springer,  clerk,  aged  twenty-one.    Em- 
pyema of  left  side  with  thoracic  fistula.    Profuse  secretion 
of  pus,  escaping  through  an  insufficient  incision.     Exten- 
sive burrowing  of  pus  under  latissimus  dorsi  and  serratus 
muscles.     The  process  was  of  one  year's  standing,  and  had 
caused  lateral  curvature  and  far-gone  emaciation.     August 
25^  1879. — Incision  and  drainage  of  the  external  abscesses 
and  of  the  left  pleural  cavity  at  the  German  Hospital. 
Exsection  of  the  eighth  rib  became  necessary,  as  the  inter- 
costal space  was  too  narrow  to  permit  of  a  safe  adjustment 

of  the  drainage-tube.  The  operation  brought  on  alarming  collapse,  which  was  over- 
come by  energetic  stimulation.  The  external  ab- 
scesses healed,  and,  though  the  secretion  from  the 
pleural  cavity  became  much  diminished,  no  tend- 
ency to  a  diminution  of  the  capacity  of  the  sac 
could  be  noticed.  By  New  Year,  1880,  the  pa- 
tient's general  condition  had  become  excellent,  and, 
no  improvement  being  visible  regarding  the  heal- 
ing of  the  thoracic  fistula,  January  3,  1880,  Est- 
lander's operation  was  performed.  By  an  ample 
vertical  incision,  commencing  in  front  of  the  axil- 
lary space  in  the  pectoral  fold,  the  third,  fourth, 
fifth,  sixth,  and  seventh  ribs  were  exposed.  Their 
periosteum  was  slit  up  longitudinally,  and  sections 
of  from  two  to  four  inches  of  the  ribs  were  re- 
moved, the  removed  pieces  being  proportional  to 
the  entire  length  of  the  several  ribs.  As  soon  as 
the  ribs  were  removed,  the  thoracic  wall  could  be 
well  depressed  into  the  hollow  of  the  cavity.  In 
order  to  retard  the  new  formation  of  bone,  the 
external  wound  was  packed  with  carbolized  gauze, 
and  healed  by  granulation.  The  pleural  hollow 
began  at  once  to  diminish  in  size,  and  April  11, 
1880,  patient  was  discharged  cured.  He  has  re- 
mained well  ever  since  that  time,  and  presented, 
Fig.  174.— Eesult  after  Estlander's  April  23,  1887,  when  the  accompanying  photo- 
K' oT  spt'e!'Trh?fp'll)f;s  Sraphs  were  taken,  the  following  status :  A  scarcely 
ease.)  noticeable  trace  of  lateral  curvature ;  the  respira- 

31 


230  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

tory  excursions  of  both  sides  of  the  thorax  identical.  All  exsected  ribs  had  re-formed 
and  occupied  a  normal  position.  Respiratory  murmur  could  be  heard  all  over  the  left 
side  of  the  thorax.     (Figs.  173  and  174). 

Case  II. — Miss  Eva  C,  aged  thirteen  and  a  half.  Thoracic  fistula  of  two  and  a 
half  years'  duration,  leading  into  a  small  cavity  holding  about  three  ounces  of  fluid, 
that  had  resisted  all  eiforts  at  cure.  May  12^  1881. — Exsection  of  sixth  and  seventh 
ribs  at  Mount  Sinai  Hospital.  September  20th. — Patient  was  discharged  cured.  In 
August,  1882.  the  healed  fistula  came  open,  with  pain  and  fever.  Septeniber  26,  1882. 
— A  sequestrum  tvro  inches  in  length,  consisting  of  a  portion  of  the  seventh  rib,  was 
extracted.     The  wound  healed  promptly,  and  the  girl's  health  remained  sound. 

The  author's  rather  incomplete  record  of  all  forms  of  empyema  of  chil- 
dren embraces  twenty-two  cases.  All  of  these  recovered  with  the  exception 
of  two — one  died  of  basilar  meningitis  ;  the  other  of  pulmonary  embolism. 

Of  the  nine  cases  of  adults,  four  were  cured  by  simple  incision  ;  two  by 
multiple  excision  of  ribs  ;  one,  a  case  of  i^erf oration  of  a  tubercular  lung 
cavity  into  the  pleura,  died  of  fatal  haemorrhage  into  the  pleura ;  and  two 
cases  were  discharged  improved,  but  not  cured. 

To  conclude,  it  may  be  said  that  the  earlier  the  operation,  the  safer  it  is, 
and  the  better  the  results  achieved  by  it. 

d.  Phlegmon  of  the  Palmar  Aspect  of  the  Hand,  of  the  Arm,  and  Axilla. 
— The  hand,  on  account  of  its  exposed  situation,  is  the  most  frequent  place 
of  small  or  more  serious  injury.  The  necessity  of  the  continued  use  of  a 
slightly  injured  hand,  and  its  contact  with  septic  matter,  lead  to  phlegmo- 
nous affections  of  different  degrees  of  intensity. 

More  serious  traumatisms,  like  incised  or  lacerated  wounds  of  the  hand, 
become  in  numerous  cases  the  seat  of  septic  inflammation,  in  consequence 
of  the  improper  and  uncleanly  primary  treatment  they  receive  from  laymen 
and  some  physicians.  Neglect  of  thorough  cleansing  and  disinfection  of 
a  small  wound  often  leads  to  direful  consequences,  that  perhaps  the  most 
skillful  and  incisive  therapy  can  not  remedy. 

Of  the  manifold  curious  practices  commonly  employed  for  stanching 
hgemorrhage  and  dressing  injuries  to  the  hand,  only  two  may  be  mentioned. 
First  comes  the  use  of  styptic  solutions.  They  are  unnecessary,  because 
digital  compression  of  short  duration  is  capable  of  stanching  even  profuse 
arterial  haemorrhage. 

The  second  practice  is  the  favorite  closure  of  soiled  wounds  about  the 
hand  with  strips  of  adhesive  plaster  or  a  suture,  without  preceding  disin- 
fection. 

Some  of  the  worst  forms  of  palmar  phlegmon  observed  by  the  author 
were  due  to  similar  ministrations  by  lay  or  medical  advisers. 

Case  1. — John  McG.,  liquor  dealer,  aged  thirty -nine.  April  30,  1886. — Chopped 
off  the  tip  of  his  index-finger  with  a  hatchet,  and  was  attended  to  immediately  by  a 
medical  quack,  who  strapped  the  injured  part  with  a  structure  of  neatly-arranged 
strips  of  adhesive  plaster  Avithout  previous  cleansing.  The  wound  was  a  smooth  and 
clean-cut  one,  and  offered  the  most  advantageous  conditions  for  the  avoidance  of  infec- 
tion. Severe  pain,  swelling,  and  fever  supervened  on  the  following  day,  but,  at  the 
advice  of  the  medical  attendant,  the  dressing  was  left  on  imdisturbed  for  four  days. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


231 


Mmj  5,  1886. — The  patient  came  under  the  care  of  the  autlior,  who  found  the  wound 
and  its  neighborhood  tightly  compressed  by  the  adhesive  strapping,  and  a  phlegmon  of 
the  sheath  of  the  Hexor  and  extensor  tendons  of  the  index  extending  into  the  inter- 
muscular planes  of  the  ball  of  the  thumb.  A  number  of  incisions  exjjosed  the  necrosed 
tendons,  and  resulted  in  a  tardy  cure  after  their  expulsion.  lie  was  discharged  cured 
July  10th. 

Case  II.— S.  A.,  laborer,  aged  thirty-five.  Presented  himself  in  January,  1881,  at 
the  German  Dispensary  with  an  incised  wound  of  the  palmar  aspect  of  the  thumb, 
and  an  extensive  subaponeurotic  phlegmon  of  the  palm  and  forearm.  The  haemor- 
rhage had  been  unsuccessfully  combated  by  the  patient  himself  witli  applications  of 
cobwebs  and  varnish.  Finally,  the  aid  of  a  druggist  was  sought,  who  soaked  a  piece 
of  lint  in  perchloride-of-iron  solution,  and  hermetically  sealed  the  wound  therewith. 
Phlegmon  set  in  promptly,  and  rapidly  extended  to  the  palmar  bursa.  The  styptic 
dressing  remained  undisturbed,  but  the  palmar  swelling  was  treated  with  diligent 
poulticing.  At  the  German  Dispensary  various  incisions  were  done  in  anaesthesia,  fol- 
lowed by  a  tedious  after-treatment  consisting  of  repeated  counter-incisions  until  cure 
was  effected.  The  removal  of  the  styptic  lint,  intimately  matted  together  with  living 
and  necrosed  tissues,  was  exceedingly  troublesome.  The  function  of  the  thumb  was 
partially  restored. 

Dorsum. — On  account  of  the  loose  arrangement  of  the  subcutaneous 
connective  tissue  of  the  dorsal  region  of  the  hand,  its  phlegmonous  affec- 
tions present  characteristics  similar  to  those  of  any  other  subcutaneous 
phlegmon.  The  presence  of  a  large  number  of  hair-follicles  favors  the 
localization  of  septic  processes  in  the  cutis,  which  lead  to  the  formation  of 
typical  furuncles  or  rarely  a  carbuncle. 

Palmar  Aspect. — The  peculiar  features  of  the  phlegmonous  processes  of 
the  palmar  aspect  of  the  fingers  and  hand  depend  upon  the  anatomical  pecu- 
liarities of  that  region.     On 

the  fingers  we   find,  instead  ^^^^"'S**'/'' 

of  the  longitudinal  and  loose 
arrangement  of  the  subcu- 
taneous tissue  of  the  dorsum, 
a  dense  net- work  of  short, 
thick  fibers,  inclosing  a  num- 
ber of  small  acini  of  fat.  The 
main  direction  of  the  course 
of  these  fibers  is  from  the 
cutis  down  to  the  periosteum, 
or  to  the  sheath  of  the  ten- 
dons, to  which  they  are  close- 
ly attached.  The  direction  of 
the  lymphatics  coincides  with 
that  of  the  connective  tissue. 
Upon  this  centripetal  course 
of  the  lymphatics  depends  the  pronounced  tendency  of  digital  inflamma- 
tions to  penetrate  to  the  bone  or  the  tendons.  The  well-known  tendency 
to  necrosis  and  the  formation  of  cutaneous,  tendinous,  or  osseous  sequestra 
is,  on  the  other  hand,  caused  by  great  tension  due  to  the  rigid  and  dense 


Fig.  175. — Transverse  section  of  terminal  phalanx,  show- 
ing aiTangement  and  direction  of  connective-tissue 
fibers.     (From  Vogt.) 


232 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


arrangement   of  the  subcutaneous 
connective  tissue.     (Fig.  175.) 

The  manner  of  the  extension  of 
phlegmonous  inflammation  within 
the  tendinous  sheaths  of  the  pal- 
mar aspect  of  the  hand  is  also  pre- 
scribed by  their  special  arrange- 
ment. Fig.  176  shows  the  sheaths 
of  the  flexors  of  the  tliumh  and  lit- 
tle finger  in  open  communication 
with  the  common  palmar  bursa, 
through  which  pass  all  the  flexor 
tendons  of  the  fingers  to  and  un- 
der the  ligamentum  capsi  transver- 
sum,  and  hence  to  the  forearm. 
The  sheaths  of  the  flexors  of  the 
index,  middle,  and  ring  fingers 
represent  separate  and  closed  re- 
ceptacles, which  terminate  on  the 
level  of  the  metacarpo-phalangeal 
joints.  For  a  short  distance  be- 
yond these  sacs  the  tendons  pos- 
sess no  sheath  proper,  but  are  im- 
mediately inclosed  by  loose  con- 
nective tissue.  We  see  correspond- 
ing to  these  three  closed  sacs  three  pointed  extensions  of  the  common  pal- 
mar bursa,  into  which  the  tendons  enter 
after  passing  through  the  sheathless  part 
of  their  course.     (Figs.  176  and  177.) 

Thumb  and  Little  Finger. — Upon 
this  arrangement  is  based  the  great  im- 
port of  the  suppurations  of  the  thumb 
and  little  finger,  mentioned  by  the  old- 
est medical  writers,  and  well  known  to 
the  common  jieople.  While  gatherings 
of  the  index,  the  middle,  and  ring  fin- 
gers often  perforate  spontaneously  near 
or  on  the  level  of  the  finger-balls  (where 
the  blind  end  of  the  closed  tendinous 
sheath  coincides  with  the  thinnest  por- 
tion of  the  palmar  aponeurosis),  suppu- 
rations of  the  thumb  and  little  finger  are 
very  apt  to,  and  as  a  matter  of  fact  often 
do,  extend  at  once  into  the  palmar  bursa. 

Tlie   knowledge   of   this   peculiarity  is  of      ^^'•^-  177.-Cnmmon  palmar  bursa  injected 
^  1  J  iirul   showiMi(  extensions  toward   thumb 

the  greatest  i)ractical  importance.  and  little  finger.    (From  Vogt.) 


Fig.  176. — a,  Blind  endings  of  sheaths  of  the  in- 
dex, middle,  and  ring  fingers,  b,  c,  Sheaths  of 
thumb  and  little  finger  openly  communicating 
with  palmar  bursa.     (From  Vogt.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  233 

Aside  from  the  acuteness  of  the  symptoms,  phlegmonous  affections 
located  on  the  palmar  aspect  of  the  hand  and  fingers  present  some  pecu- 
liarities, the  diagnostic  significance  of  wliich  must  be  mentioned.  Redness 
of  the  skin  is  generally  absent,  to  ajipear  only  when  the  process  has  worked 
its  way  up  to  the  skin.  (Edema  is  moderate,  and  is  often  overlooked  by  in- 
experienced observers,  who  are  misled  by  the  (jedema  and  redness  of  the  dor- 
sal soft  23arts  to  look  there,  and  not  on  the  palmar  side,  for  the  focus  of  the 
disturbance. 

The  subjective  symptoms  are  very  distressing,  high  fever  and  intense 
pain  being  the  rule. 

Treatment. — Prevention  of  phlegmon  by  guarding  against  the  infection 
of  large  or  small  injuries  of  the  integument  is  very  profitable.  Small 
excoriations  and  shallow  cuts  should  be  cleansed  and  touched  with  acetic- 
acid.  Punctures  should  be  well  sucked  and  bled  and  sealed  with  an  acetic 
acid  eschar  ;  or,  if  there  be  the  least  suspicion  of  infection  by  an  unclean 
sharp-pointed  object,  dilatation  of  the  small  hole,  thorough  wiping  out  of 
the  track  with  sublimate  lotion,  and  drainage  by  means  of  a  few  short  pieces 
of  catgut  laid  into  the  bottom  of  the  puncture  are  to  be  employed.  In  this 
latter  class  of  cases  a  moist  dressing  is  appropriate. 

In  the  presence  of  an  inflammation  that  is  evidently  gathering  mo- 
mentum, all  attempts  at  an  abortive  treatment  are  risky,  as  the  deceptive 
relief  afforded  by  hot  applications  is  very  apt  to  induce  patient  and  physician 
to  be  tardy  with  the  application  of  the  best  and  surest  antiphlogistic  :  the 
Jcnife.  By  the  time  that  the  unbearable  suffering  finally  compels  energetic 
treatment,  suppuration  requires  a  long  incision,  and  necrosis  of  a  phalanx 
or  tendon  may  be  established.  At  first  it  might  have  teen  prevented  ly  a 
much  smaller  incision — in  fact,  hy  a  mere  puncture.  The  cases  where  a 
timely  deep  puncture  with  a  tenotomy  knife  released  one  or  a  few  drops  of 
pus  to  the  most  intense  relief  of  the  patient  were  very  numerous  in  the 
author's  dispensary  experience,  and  he  can  not  recommend  this  truly  con- 
servative procedure  in  warm  enough  terms.  Instead  of  a  terribly  painful  and 
tedious  illness  ending  in  more  or  less  of  destruction,  rapid  healing  of  the 
small  wound  under  the  moist  dressing  will  be  the  rule.  And,  if  we  consider 
that  local  anaesthesia  by  cocaine  or  the  ether  spray  (both  more  effective  if 
combined  with  artificial  anaemia)  has  deprived  incision  of  all  its  terrors, 
hesitation  and  poulticing  become  a  culpable  offense  against  the  dictates  of 
common  sense. 

The  diagnosis  of  the  exact  locality  of  beginning  suppuration  is  easily 
made  by  the  aid  of  the  unmistakable  sensations  of  the  patient.  Gentle 
pressure  by  a  probe  upon  different  points  of  the  affected  region,  made  to 
cover  successively  and  in  a  methodical  way  the  entire  area  in  the  shape  of  a 
spiral,  will  soon  detect  the  most  painful  spot.  If  one  or  two  repetitions  of 
this  process  confirm  the  result  of  the  first  search,  no  hesitation  need  be  felt. 
The  point  thus  found  is  marked  by  a  shallow  scratch  or  otherwise,  the 
finger  or  hand  is  anaesthetized,  and  the  tenotomy  knife  is  boldly  thrust 
down  to  the  periosteum.      If  a  few  drops  of  pus  escape  only,   this  will 


2U 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


suffice  ;  if  more,  tlie  juiiicture  should  be  at  once  proportionately  enlarged, 
thoroughly  irrigated,  and  covered  with  a  moist  dressing.  As  the  affection 
generally  extends  to  the  periosteum  or  tendon,  the  incision  should  always 
be  carried  down  to  one  or  the  other,  and  should  be  longitudinal  to  avoid 
injury  of  vessels  or  tendons. 

Suhfascial  phlegmons  of  the  palm  should  be  also  promptly  and  suffi- 
ciently incised.     The  adjoining  diagram  (Fig.  178)  will  be  found  very  useful 

in  pointing  out  the  small  area  which  should 
be  avoided  on  account  of  the  superficial  pal- 
mar arch.  It  is  situated  between  the  first 
and  last  strokes  of  the  capital  M  that  marks 
the  palm.  After  the  aponeurosis  has  been 
cut  through,  any  point  of  the  palm  can  be 
reached  from  the  lines  marked  out  on  Fig. 
178,  by  Hilton-Eoser's  method. 

Incision  is  advisable  even  at  the  risk  of 
cutting  the  palmar  arch,  as  the  hemorrhage 
thus  caused  can  be  easily  stopped  by  ligatur- 
ing the  vessel  in  an  ample  incision,  and  Es- 
march's  band  will  effectively  prevent  undue 
loss  of  blood  during  the  operation. 

There  is  no  region  of  the  human  body 
where  senseless  poulticing  of  phlegmons  has 
done  more  harm,  and  timely  incision  can  do 
more  good,  than  in  the  palm. 

Case. — M.  M.,  saddler,  ajred  sixty-five,  had  in 
the  latter  part  of  August,  1885,  a  boil  of  the  face, 
which  he  was  in  the  habit  of  dressing  himself.  At 
the  same  time  he  infected  a  small  scratch  of  liis 
right  forefinger,  from  which  developed  a  felon.  The 
family  attendant  ordered  poulticing,  which  was  Tcept 
up  tminterrwptedly  for  more  than  three  weelcs.  Not  one  incision  had  heen  made^  and 
when  the  author  saw  the  patient,  September  28,  1885,  about  twenty-four  hours  before 
his  death  from  septicaemia,  the  hand  and  entire  arm  presented  a  terrible  condition  of 
phlegmonous  destruction.  Not  one  tendon,  no  Joint,  was  free  from  suppuration,  and 
a  number  of  phalanges  were  necrosed  ;  tbe  skin  was  extensively  detached  and  repre- 
sented a  boggy  bag,  from  which  pus  flowed  copiously  through  a  number  of  smaller 
and  larger  defects  due  to  sloughing.  Diphtheria  of  the  throat,  tongue,  and  mouth  had 
also  developed  the  day  before  the  consultation,  and  the  wretched  general  condition  of 
the  y)atient  put  any  operative  measure  out  of  question.  The  inquiry,  how  such  a  state 
of  things  could  come  about,  drew  the  reply  that  "there  were  plenty  of  openings,  they 
seemed  to  discharge yree^jr  und  nicely,  and  tlierefore  surgical  interference  was  refrained 
from." 

Neglected  cases,  where  the  suppurative  process  has  attained  wide  pro- 
portions, should  be  treated  on  general  princii)les  laid  down  regarding  the 
management  of  complicated  abscesses.  All  recesses  should  be  found  out, 
seyjarately  incised,  and  drained.     Where  in  the  course  of  a  long-continued 


u  R  ' 

Fig.  178. — Straight  lines  markin"; 
the  places  where  incisions  can  be 
safely  made.  The  space  between 
the  first  and  last  strokes  of  the 
capital  M,  marking  the  palm, 
should  be  avoided.    (From  Vogt.) 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


235 


process  the  soft  tissues  luive  been  more  or  less  permeated  by  the  septic 
poison,  and  multiple  small  abscesses  with  a  sanious  discharge  have  estab- 
lislied  themselves,  the  enormous  swelling  will  render  efficient  drainage  very- 
difficult  or  even  impossible. 

Vertical  suspension  on  Volkmanti's  arm-splint  with  continuous  irriga- 
tion will  often  do  here  very  effective  service.     Its  detail  is  as  follows  : 

After  the  proper  incisions  are  made  and  the  requisite  number  of  drainage- 
tnbes  have  been  inserted,  the  arm  is  enveloped  in  gauze,  is  loosely  attached 
to  the  splint  (Fig.  179)  by  a  roller  bandage,  and  is  suspended  from  the  ceil- 
ing or  a  suitable  frame.  One  or  more  irri- 
gators filled  with  a  very  weak  sublimated  or 
salicylated  lotion  being  also  suspended,  their 
nozzles  are  connected  with  one  or  more  of  the 
uppermost  drainage-tubes.  A  rubber  blanket 
is  so  arranged  beneath  the  suspended  limb  as 
to  catch  all  the  drippings  and  to  conduct 
them  into  a  bucket  placed  alongside  the  bed. 
The  flow  of  the  irrigating  fluid  is  regulated 
by  i^ushing  a  match-stick  or  a  straw  into  the 
nozzle  of  the  irrigator.  In  this  manner,  ac- 
cording to  necessity,  a  free  current  or  the 
escape  of  the  fluid  in  drops  can  be  effected. 

If  the  entire  limb  require  irrigation,  the 
use  of  many  irrigators  can  be  obviated  by  a 
simple  contrivance  recommended  by  Starcke. 
A  tin  tube,  open  at  one  end,  and  provided 
with  a  number  of  nipples,  is  connected  with 
a  large  irrigator.  On  the  nipples  rubber  tubes 
are  slipped,  and  are  conducted  to  the  several 
drainage-tubes,  with  which  connection  is  es- 
tablished through  short  pieces  of  glass  tubing. 
(Fig.  180.) 

Continuous  immersion  in  a  weak  antisep- 
tic lotion  is  a  very  simple  and  effective  sub- 
stitute for  permanent  irrigation,  although  it 
precludes  the  advantages  of  vertical  suspen- 
sion. The  lotion  should  be  changed  from 
three  to  four  times  daily,  and  its  tempera- 
ture is  to  be  regulated  by  the  patient's  sen- 
sations.    Some  will  have  it  warm,  others  will 

prefer  a  cool  bath.  By  placing  one  or  two  alcohol  lamps  underneath  the 
tin  vessel  containing  the  bath,  an  even  temperature  can  be  maintained. 

Case  I. — Hugo  B.,  laborer,  aged  twenty-eight,  admitted,  March  11,  1886,  to  the 
German  Hospital  with  extensive  phlegmon  of  the  palm,  consequent  upon  an  injury  to 
the  middle  finger.  The  corresponding  metacarpo-phalangeal  joint  was  destroyed.  The 
house-surgeon  exarticulated  the  third  finger,  and  made  a  number  of  incisions  in  the 


Fig-.  1Y9. — Volkmann's  arm-splint 
for  vertical  suspension. 


236 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


palm,  liberating  a  good  deal  of  pus.  By  March  12th  the  temperature  had  been  some- 
what lowered,  but  an  ominous  swelling  of  the  forearm  appeared.  March  18th. — A 
number  of  incisions  were  made  on  the  flexor  side  of  the  arm  into  the  suppurating 

tendinous   sheaths.     Moist  dressings  and   elevated 
posture.      Continuous  high  fever.      March  25th. — 
Renewed  incisions  on  dorsum  of  forearm,  exposing 
the  extensor  tendons.    Swelling  of  the  arm  and  axil- 
lary glands.     High  fever.    The  affection  proving  iin- 
controUable,   on   account  of  the  uniform   purulent 
infiltration  of  the  soft  tissues,  continuous  immersion 
of  the  limb  in  a  1 :  5,000  solution  of  corrosive  sub- 
limate was  resorted  to,  and  was  constantly  employed 
during  the  months  of  April  and  May.    No  mercurial 
toxic  symptoms  whatever  could  be  observed  during 
this  period  of  time.     The  swelling  of  the  axillary 
glands  disappeared  a  few  days  after  the  commence- 
ment of  this  treatment,  and  a  tardy  disappearance 
of  the  febrile  symptoms  followed  pari  passu  with 
the  detachment  of  a  number  of  gangrenous  muscles 
and  tendons.   Toward  the  end  of  May  all  the  sloughs 
were  detached,  and  the 
little  finger  was  removed 
on  account  of  necrosis  of 
the  phalanges.     During 
June  and  July  a  number 
of  small  abscesses  devel- 
oped on  the   hand  and 
along  the  arm,  and  were 
successively  incised.  End 
of  July  all  incisions  were 
healed.     Active  and  pas- 
sive motions  and  massage 
restored   a    part  of  the 
motion  of  the  wrist,  the 
thumb,  and  index.     The 
patient,  of  whose  limb  and  life  we  had  despaired,  was  discharged  cured  aud  in  a 
florid  condition  August  26th. 

Case  II. — A.  W.,  laborer,  aged  thirty-two,  admitted,  August  IV,  1886,  to  German 
Hospital.  August  7th. — Sustained  an  injury  of  the  left  forearm.  The  profuse  haem- 
orrhage was  stopped  with  a  tourniquet.  The  physician  left  this  instrument  in  situ., 
and  ordered  to  tighten  tbe  screw  in  case  of  renewed  loss  of  blood.  The  patient,  fol- 
lowing the  advice  of  his  physician,  tightened  the  tourniquet  as  directed.  August  9th. 
— The  forearm  swelled  up  considerably,  and  assumed  a  bluish  cast ;  at  the  same  time 
several  chills  and  high  fever  set  in.  Increasing  swelling.  A  homoeopathic  practitioner 
of  Newark  made  a  few  superficial  incisions,  and,  seeing  no  improvement  therefrom, 
proposed  amputation.  On  admission  the  patient  presented  a  pitiable  condition  of  sep- 
ticaemia. Temperature,  105"8°  Fahr.  The  pulse  was  hardly  noticeable,  respiration 
very  frequent,  the  patient  cyanosed  and  somnolent,  his  body  covered  with  cold  per- 
spiration. The  entire  left  arm  was  enormously  swollen,  the  skin  of  the  forearm  exten- 
sively discolored,  and  fluctuation  was  noted  in  many  places.  On  account  of  the  collapsed 
condition  of  the  patient,  only  a  few  incisions  were  made  to  relieve  the  pus  and  to  reduce 


Fig.  180. — Continuous  irrigation  by  means  of  Starcke's  tube,  in 
vertical  suspension. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  237 

tension.  Aside  from  tlie  larye  abscesses,  a  uniform  purulent  infiltration  of  the  tissues 
was  found.  August  18th. — Niunerous  incisions  were  made  in  ansesthesia,  the  entire 
forearm  exhibiting-  a  state  of  ichorous  infiltration.  Necrosed  portions  of  the  skin  and 
of  various  muscles  were  ablated,  and  a  number  of  drainage-tubes  were  inserted.  The 
arm  was  kept  continuously  immersed  in  a  tepid  bath  for  four  days  without  an  appreci- 
able improvement  of  the  local  or  general  disturbance.  August  20th. — The  arm  was 
vertically  suspended,  and  continuous  irrigation  by  a  weak  mercurial  lotion  was  estab- 
lished and  kept  up  until  September  18th.  This  change  was  followed  by  slow  but 
unmistakable  improvement,  interrupted  by  occasional  rises  of  temperature  due  to 
retention.  The  entire  integument  of  the  volar  side  of  the  arm  was  lost  by  necrosis, 
and  the  defect  had  to  be  covered  by  a  number  of  skin-grafts.  The  patient  was  dis- 
charged cured  November  29th,  vrith  slight  mobility  of  the  wrist  and  the  metacarpo- 
phalangeal joints. 

By  these  means  many  a  limb  can  be  saved.  The  detachment  of  slough- 
ing tissues  should  be  facilitated  by  the  use  of  scissors  and  forceps,  and  the 
rule  should  be  upheld  not  to  sacrifice  any  part  of  the  lumcl  that  is  viable. 
Even  the  most  sorry-looking,  shapeless,  and  immovable  rudiments  of  this 
useful  organ  will  be  of  great  value  to  the  patient  afterward. 

Should  all  these  means  be  of  no  avail  in  checking  the  progress  of  sup- 
puration, amputation  will  haye  to  be  considered  as  a  last  life-saving  remedy. 

Case. — Ernst  _B.,  shoemaker,  aged  sixty-nine.  Had  been  for  years  attended  to  at 
the  German  Dispensary  for  a  chronic  fungous  affection  of  the  wrist.  In  the  fall  of 
1885  a  phlegmonous  inflammation  started  from  one  of  the  many  fistulse  present,  grad- 
ually involving  the  entire  hand,  wrist,  and  part  of  the  forearm.  A  large  number  of 
incisions  had  been  made,  but  the  trouble  crept  steadily  from  one  joint  to  another, 
and  along  the  tendons,  until  the  hand  presented  one  swollen,  shapeless,  festering  mass. 
February  13,  1886. — Amputation  of  the  forearm  was  done  at  its  upper  third.  Primary 
union  followed  throughout. 

Joints  of  the  Upper  Extremity. — Injury  and  infection  of  the  metacarpo- 
phalangeal or  first  inter  phalangeal  joints  frequently  take  place  during  a 
rough-and-tumble  fight,  when  the  fist  of  a  fighter  hits  the  incisors  of  his 
antagonist.  The  author  has  treated  four  cases  of  this  kind  within  the  last 
seven  years.  In  one,  syjDhilis  followed  a  very  obstinate  suppuration  of  the 
first  interphalangeal  joint  of  the  right  index. 

But  often  enough  secondary  suppuration  of  the  finger-joints  is  caused  by 
extension  of  a  neglected  subcutaneous  or  tendineal  phlegmon. 

Note. — A  very  acute  phlegmon  of  the  elbow-joint  came  under  the  observation  of  the  author 
at  Mount  Sinai  Hospital.  A  compound  dislocation  was  freshly  admitted,  and  was  reduced  and 
dvessed  so-called  "  antiseptically  "  by  a  junior  member  of  the  house  staff.  Suppuration  followed 
promptly,  the  sutures  had  to  be  removed,  a  number  of  incisions  had  to  be  made,  and  a  tardy 
cure  was  efPected,  resulting  in  bony  anchylosis  of  the  elbow  at  an  acute  angle.  (See  case  of 
Samuel  Krongold,  page  20Y.) 

Suppuration  of  the  finger-joints  usually  terminates  in  anchylosis.  In 
many  cases  this  untoward  result  can  be  prevented  by  exsecfion  and  subse- 
quent careful  treatment  by  passive  and  active  movements.  However,  this 
operation  should  never  be  undertaken  before  the  phlegmonous  process  has 

terminated,  and  suppuration  has  assumed  a  bland  character.     The  author's 

32 


238  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

results  achieved  by  this  little  operation  are  very  satisfactory,  and  the  pro- 
cedure can  be  warmly  recommended.  As  a  rule,  a  more  or  less  movable 
joint  results,  which-  certainly  is  preferable  to  a  stiff  finger.  In  one  case 
douUe  exsection  luas  successfully  done  after  a  felon  of  the  thumb,  involving 
the  metacarpo-phalangeal  and  interphalangeal  joints.  To  this  end,  how- 
ever, preservation  of  the  tendons  is  a  necessary  condition. 

Case  I. — Frank  P.,  liquor  dealer,  aged  thirty-six.  Seen  January  15,  1885,  with 
Dr.  H.  Balser,  on  account  of  a  phlegmon  of  the  right  index  and  palm,  caused  hy  open 
injury  to  the  metacarpo-phahmgeal  joint.  The  injury  was  sustained,  January  1,  1885, 
during  a  fight  by  violent  contact  with  the  antagonist's  teeth.  The  process  had  lost  its 
virulent  character,  and  subperiosteal  exsection,  by  two  lateral  incisions,  was  done 
January  16th.  The  cure  was  uninterrupted.  The  flexor  profundus  tendon  had  sloughed 
away,  hence  only  the  first  phalanx  could  be  actively  bent.  Patient  discharged  cured 
February  22,  1885. 

Case  II.— S.  L.,  baker,  aged  twenty-nine.  Seen  in  December,  1882,  in  consulta- 
tion with  Dr.  H.  Kudlich.  Eecent  phlegmon  of  thumb,  suppuration  of  tendineal 
slieath  of  flexors  and  of  both  the  joints  of  the  thumb.  December  12th. — Three  in- 
cisions released  the  tension.  After  the  cessation  of  the  acute  stage  of  the  inflamma- 
tion, December  29th,  exsection  of  metacarpo-phalangeal  and  interphalangeal  joints 
was  done.     Uninterrupted  cure;  good  function  preserved. 

Phlegmon  of  the  olecranic  bursa  is  characterized  by  very  acute  local  and 
general  disturbance  due  to  the  great  tension  maintained  by  the  dense  cap- 
sule of  the  sac.  Free  incision  supplemented  by  Volkmann's  punctuation 
of  the  infiltrated  skin  of  the  vicinity  is  promptly  followed  by  relief  and  a 
rapid  cure. 

Suppuration  of  the  cubital  or  axillary  lymphatic  glands  is  a  very  com- 
mon complication  of  limited  or  extensive  septic  inflammatory  processes  af- 
fecting the  hand  and  arm. 

Two  forms  of  suppuration  have  to  be  distinguished :  One  of  an  acute  char- 
acter, terminating  in  the  formation  of  one  more  or  less  extensive  abscess, 
the  result  of  confluence  of  several  foci,  A  spontaneous  or  artificial  evacua- 
tion generally  leads  to  rapid  cure. 

Another  more  chronic  and  very  obstinate  form,  in  which  a  group  of 
lymphatic  glands  is  attacked  in  succession,  leading  to  the  formation  of  a 
series  of  deep-seated  abscesses  and  a  number  of  sinuses.  This  form  is  gener- 
ally observed  in  poorly-nourished  subjects.  The  individuality  of  the  glands 
is  not  destroyed  rapidly  as  in  the  more  acute  form,  but  their  slow  and 
gradual  destruction  is  accomplished  by  a  tedious  ulcerative  process.  Long 
before  the  glandular  ulceration  is  terminated,  cicatricial  contraction  of  the 
sinuses  leading  through  healthy  tissues  will  occur,  and  cause  retention. 
This  is  followed  by  an  exacerbation  of  the  local  and  general  symjitoms,  and 
results  in  the  formation  of  a  new  abscess  and  sinus.  The  interminable 
suppuration  often  leads  to  serious  deterioration  of  the  general  condition, 
marked  by  emaciation,  night-sweats,  and  loss  of  appetite.  As  these  cases 
represent  an  aggregation  of  a  large  number  of  septic  foci  imbedded  in  dense 
tissue,  one  or  even  more  incisions  will  not  be  adequate  for  efficient  drainage, 
and  in  spite  of  them  tlie  process  will  continue. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  239 

Extirpation  of  the  entire  group  of  ajfected  lympli-gkmds  by  careful 
preparation  is  tlieir  best  therapy.  As  rupturing  of  one  or  more  of  the 
broken-down  glands,  and  soiling  of  the  wound  by  their  contents,  can  not 
always  be  avoided,  closure  by  sutures  is  best  omitted.  Thorough  irrigation 
with  corrosive-sublimate  lotion,  a  loose  packing  with  moist  gauze,  and  a 
moist  dressing  are  appropriate. 

Case  I. — Emma  Epple,  servant,  aged  seventeen.  Admitted  to  German  Hospital 
March  31,  1886.  As  the  consequence  of  a  "run-around"  treated  by  poulticing,  sup- 
puration of  the  lymphatic  glands  of  the  left  axilla  developed.  The  arm-pit  was  filled 
with  a  densely  infiltrated  large  mass  of  intumescent  and  very  painful  glands.  The 
continuous  fever  and  sleeplessness  had  produced  an  alarming  degree  of  anaBmia  and 
debihty,  characterized  by  night-sweats  and  loss  of  appetite.  As  no  fluctuation  could 
be  made  out,  and  presumably  all  the  affected  glands  were  in  a  state  of  suppuration, 
extirpation  of  th%  entire  glandular  mass  was  advised,  and  carried  into  effect  April  3d. 
Dissection  of  the  tumor  from  the  axillary  vessels  was  rather  difficult,  and,  one  of  the 
tenacula  lacerating  one  of  the  brittle  glands,  a  few  drops  of  pus  exuded  into  the 
wound.  After  thorough  irrigation  with  corrosive-sublimate  solution,  the  wound  was 
closed  by  suture,  and  an  antiseptic  moist  dressing  was  applied.  Previous  to  this  a  sepa- 
rate incision  was  made  at  the  most  dependent  poi'tion  of  the  cavity  for  the  reception  of 
a  stout  drainage-tube.  A  sharp  chill  and  much  pain  followed  the  next  day  after  the 
operation.  Undoubtedly,  infection  of  the  cavity  by  contact  with  the  escaped  pus  had 
taken  place.  The  dressings  being  removed,  pus  was  seen  oozing  out  of  the  drainage- 
tube.  Daily  change  of  dressings  and  irrigation  of  the  cavity  with  mercurial  lotion  was 
followed  by  rapid  improvement,  and  the  patient  was  discharged  cured,  May  7th. 

Case  II. — 0.  H.,  butcher,  aged  sixty-two.  Slightly  cut  the  dorsum  of  his  left 
middle  finger,  October  15,  1885,  with  a  butcher-knife.  A  phlegmon  developed,  and 
was  treated  by  the  patient  himself  with  poulticing  till  October  27th,  when  spontaneous 
evacuation  took  place.  For  a  few  days  previous  to  this  date,  intumescence  of  the  cu- 
bital lymphatic  glands  was  noted.  Octoler  28tTi. — The  patient  came  under  the  author's 
care  with  an  angry  swelling  of  the  region  of  the  cubital  glands.  Incision  was  proposed 
and  declined.  After  a  couple  of  wretched  nights  the  patient  consented  to  incision, 
which  was  done  under  chloroform,  October  31st.  A  small  amount  of  pus  came  away, 
and  a  drainage-tube  and  moist  dressings  were  applied.  The  momentary  improvement 
soon  gave  way  to  renewed  attacks  of  pain  and  swelling,  apparently  due  to  succes- 
sive suppuration  of  several  glands.  Much  difficulty  was  experienced  in  keeping  the 
drainage-tube  in  situ,  the  external  wound  showing  a  great  tendency  to  cicatrization, 
while  the  slow  ulceration  of  the  glandular  tissue  was  still  progressing.  An  extirpation 
of  the  glandular  mass  would  have  been  more  serviceable  in  this  case  than  a  simple 
incision.  After  a  tedious  and  troublesome  course  of  treatment,  the  case  was  finally 
discharged  cured,  December  37th. 

e.  Suppurative  Affections  of  the  Lower  Extremity : 

(a)  Ii^GEOWisr  Toe-Nail. — The  most  common  cause  of  this  distressing 
affection  is  the  improper  care  of  the  toe-nails.  Sweating  feet,  in  combina- 
tion with  lack  of  cleanliness,  improperly  trimmed  toe-nails,  and  narrow-toed 
shoes,  offer  the  best  conditions  for  the  development  of  ulcerative  processes 
near  the  anterior  edge  of  the  nail.  Whenever  the  nail  is  trimmed  off  too 
short,  the  adjacent  skin  will  overlap  its  angle  (Fig.  181).  The  epidermis  be- 
ing macerated  and  soft  from  the  profuse  sweating,  a, small  amount  of  friction 
between  the  edge  of  the  nail  and  the  skin  will  be  sufficient  to  cause  an  exco- 


240 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


v^xxvV»V 


Fig.  181. — a,  Wrong  way  of  trimming 
toe-nail,     b,  Tne  right  way. 


riation.  The  pj'ogenic  germs,  so  abundantly  present  in  the  fetid  epidermidal 
masses  of  sweating  feet,  will  not  only  come  in  contact  with  the  raw  surface, 
but  will  be  rubbed  into  the  open  lymphatics  by  each  successive  step  taken  by 

the  individual.  An  ulcerative  inflam- 
mation of  the  parts  will  result,  which 
offers  poor  conditions  for  natural  drain- 
age. Eetention  of  the  septic  secretions 
leads  to  chronic  suppuration,  and  to 
the  extension  of  the  process  backward 
toward  the  root  of  and  also  under  the 
nail,  until  more  or  less  of  it  becomes 
undermined  and  detached.  Exuberant 
granulations,  subject  to  frequent  ulcer- 
ative destruction,  spring  up  from  the 
hypertrophied  and  infiltrated  overlap- 
ping skin,  and,  if  unchecked,  the  disorder  terminates  in  the  loss  of  the  nail. 
Occasionally  an  ingrown  toe-nail  is  the  starting-point  of  phlegmon  or  ery- 
sipelas of  the  dorsum  of  the  foot.  The  initial  stages  of  the  mischief  can 
often  be  successfully  met  with  a  careful  local  treatment.  Disinfecting  baths, 
sprinkling  of  alum  and  salicylic  powder  (alum,  usti,  3  ij  ;  acidi  salicyl., 
3  ss  ;  bismuthi  subnitr.,  |  ijss)  into  the  stockings,  which  should  be  daily 
changed,  and  the  packing  of  salicylated  or  iodoformed  cotton  or  lint  under 
the  edge  of  the  nail,  frequently  result  in  alleviation,  if  not  a  cure,  of  the 
affection. 

More  inveterate  or  extensive  cases  in  persons  unable  to  devote  the  neces- 
sary care  and  time  to  the  treatment  of  this  trouble  will  be  best  cured  by 
operation.  After  careful  scrubbing  and  disinfection,  the  toe  is  rendered 
anaemic  by  constriction  of  its  root  with  a  piece  of  rubber  tubing.  Local 
anaesthesia  is  produced  by  either  an  injection  of  a  cocaine  solution  or  the 
use  of  Eichardson's  ether-spray.  The 
point  of  a  bistoury  is  (Fig.  182) 
placed  against  the  exuberant  tissues 
adjoining  the  nail,  and  is  thrust 
through  the  margin  of  the  toe.  It 
is  carried  forward  until  the  integu 
ment  is  separated  in  the  shape  of  a 
longitudinal  flap.  Then  the  knife 
is  reversed  and  carried  back  well  be- 
yond the  matrix  of  the  nail,  where 
the  flap  (c)  is  cut  off. 

The  pointed  blade  of  a  straight 
pair  of  scissors  is  placed  under  the  an- 
terior margin  of  the  nail  (Fig.  182,  A,  b)  just  beyond  tlie  limit  of  the  disease, 
and,  being  thrust  under  it,  cuts  through  the  nail  in  an  antero-posterior  direc- 
tion well  Vjack  of  the  matrix.  One  blade  of  a  stout  pair  of  dressing-forceps  is 
next  insinuated  into  the  slit  in  the  nail  and  under  the  loose  segment.    This, 


Fifj.  182. — Operation  for  ingrown  toe-nail. 
A,  15,  Line  of  section  through  the  nail 
and  matrix. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  Ml 

being  firmly  grasped,  is  evulsed  with  an  outward  rotating  motion.  Good 
care  must  be  taken  not  to  leave  behind  any  shreds  of  the  cut-ott"  matrix. 
Any  granulations  are  scraped  away  with  a  sharp  spoon,  and  the  Avound  is 
well  irrigated  with  mercuric  lotion.  A  strij)  of  rubber  tissue  well  soaked 
in  carbolic  lotion,  and  just  large  enough  to  cover  the  wound,  is  placed  next 
to  it ;  over  this  comes  a  strip  of  iodoformed  gauze  and  a  small  disinfected 
sponge,  the  latter  to  exercise  elastic  pressure  for  the  prevention  of  undue 
haemorrhage  ;  finally  comes  a  light,  compressive  7)ioist  dressing,  fastened 
by  a  roller  bandage.  While  the  patient's  foot  is  held  elevated,  the  rubber 
band  is  removed.  The  first  dressing  can  be  left  on  for  a  week  or  even  two 
weeks.  Being  moist,  it  will  peel  oif  easily  when  removed,  and,  according 
to  its  size,  the  wound  will  be  found  either  partly  or  entirely  cicatrized  over. 
Care  must  be  taken  not  to  compress  the  toe  too  much,  as  necrosis  of  the 
skin  by  pressure  may  develop  and  retard  the  healing. 

The  author  has  treated  over  a  hundred  of  these  cases  in  the  manner  de- 
scribed with  the  best  results,  the  majority  being  patients  of  the  German 
Dispensary,  who  walked  to  and  from  the  institution  during  the  time  of 
treatment. 

(b)  CHEOisric  Ulcers  of  the  Leg. — Neglected  excoriations  or  abrasions 
of  the  skin  belonging  to  the  lower  third  of  the  leg  are  the  most  common 
starting-point  of  ulcerous  processes.  Varices  due  to  stagnation  of  the  venous 
circulation  render  the  progressive  invasion  of  new  areas  of  tissue  by  micro- 
cocci, ever  present  in  the  putrescent  discharges,  especially  easy.  Conse- 
quently, ulcerative  destruction  develops.  The  successful  treatment  of  this 
condition  must  be  based  upon  an  elimination  of  the  causal  factors.  Pre- 
vention or  elimination  of  decomposition  by  antiseptics,  and  an  improve- 
ment of  the  circulatory  conditions  by  elevation  of  the  limb  or  its  elastic 
compression,  form  the  cardinal  points  of  our  therapy. 

The  affected  limb  is  carefully  cleansed  with  soap  and  a  soft  flannel  rag 
until  all  the  crusts  of  inspissated  secretion  and  epidermis  are  removed.  This 
process  will  be  greatly  facilitated  by  packing  of  the  parts  in  strips  of  lint 
saturated  with  vaseline  or  unsalted  lard  the  night  previous  to  the  cleansing 
bath.  Plain  water  should  never  be  used  on  account  of  its  irritating  quali- 
ties and  its  liability  to  cause  eczema.  After  the  bath  the  soap-suds  should 
be  simply  wiped  off  with  a  soft  towel.  The  ulcer  is  well  mopped  with  a 
1  :  1,000  solution  of  corrosive  sublimate,  or,  where  the  stench  is  very  intense, 
with  a  4  :  1,000  solution  of  permanganate  of  potash.  Iodoform  powder  is 
dusted  over  the  ulcer,  and  a  suitable  patch  of  rubber  tissue  is  placed  next 
to  it.  The  eczematous  skin  in  the  vicinity  is  well  anointed  with  vaseline 
or  an  astringent  salve,  and  a  regular  antiseptic  dressing  is  snugly  bandaged 
on  to  the  ulcer,  the  roller  bandage  extending  from  the  toes  to  the  knee-joint. 
This  dressing  need  not  be  removed  before  tw^o  or  three  days,  the  frequency 
of  renewal  being  dependent  upon  the  quantity  of  the  discharge.  As  soon 
as  cicatrization  is  well  advanced,  a  simi)ler  dressing,  consisting  of  a  strap- 
ping of  mercurial  plaster  covered  with  a  pad  of  absorbent  cotton,  held  down 
by  a  Martin's  elastic  bandage,  can  be  substituted  therefor,  and  the  patient 


242  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

may  be  permitted  to  abandon  the  recumbent  posture  and  take  moderate 
exercise.  When  cicatrization  is  completed,  a  well-cleansed  elastic  bandage 
will  suffice  to  prevent  renewed  ulceration.  It  is  most  convenient  to  have 
two  elastic  bandages,  to  be  worn  alternatingly.  Under  this  simple  treatment 
most  ulcers  of  the  leg,  even  those  surrounded  by  callous  edges,  will  develop 
healthy  granulations,  and  will  heal  kindly.  Due  regard  should  be  paid  to 
the  general  condition  of  the  patient,  as  on  it  may  depend  to  a  great  measure 
the  rapidity  of  the  cure.  A  marastic  state  of  the  system  should  be  improved 
by  suitable  nutritious  diet ;  the  deterioration  of  the  general  health  of  those 
addicted  to  the  immoderate  use  of  alcohol  should  be  remedied  by  a  proper 
regulation  of  their  habits. 

In  cases  of  very  extensive  loss  of  integument,  skin-grafting  will  give  very 
gratifying  results.  If  this  should  fail,  circumcision  of  the  callous  ulcer  by 
a  deep  cut  carried  through  the  fascia,  according  to  Nussbaum,  may  be  tried. 
The  incision  should  be  placed  about  oue  third  of  an  inch  from  the  edge  of 
the  sore. 

(c)  Acute  Suppukation  op  the  Pebpatellaky  Bursa. — Servant-girls 
and  scrub-womeu,  in  short,  persons  frequently  subject  to  house-maid's 
knee  or  simple  synovitis  of  the  prepatellary  bursa,  are  frequently  victims  to 
phlegmonous  inflammation  of  the  same  organ.  The  symptoms  are  those  of 
a  subcutaneous  phlegmon,  heightened  by  the  circumstance  that,  the  phleg- 
monous focus  being  encapsulated,  great  tension  is  apt  to  develop.  Extensive 
necrosis  and  serious  septic  intoxication  must  result  if  no  timely  relief  is 
afforded. 

Dense,  hard  infiltration  and  a  deep-red  flush  of  the  prepatellary  region, 
with  oedema,  high  fever,  and  marked  sickness,  are  present.  The  general 
intumescence  may  cause  errors  in  diagnosis,  as  inexperienced  observers  are 
apt  to  look  for  the  source  of  the  trouble  within  the  knee-joint.  This  mis- 
take can  be  avoided  by  noting  that  in  septic  bursitis  the  point  of  the  most 
intense  swelling,  redness,  and  pressure-pain  is  over  the  patella,  whereas  in 
gonitis  pressure  over  the  juncture  of  the  femur  and  tibia  laterally  of  the 
patella  is  most  painful,  and  the  patella  can  be  distinctly  felt  floating  on  top 
of  the  exudation  within  the  knee.  A  free  incision  into  the  bursa,  together 
with  Volkmann's  multiple  jjuncture  of  the  inflamed  skin,  is  the  proper 
treatment.  The  cavity  should  be  well  irrigated  with  corrosive-sublimate 
lotion,  loosely  packed  with  strips  of  iodoformed  gauze,  and  inclosed  in  a 
moist  dressing,  which  should  be  daily  changed. 

(d)  Acute  Suppuration  of  the  Knee-joikt  is  one  of  the  most  formi- 
dable types  of  phlegmon.  On  its  prompt  recognition  and  energetic  treat- 
ment may  de^Dcnd  the  safety  of  limb  and  life.  It  should  be  well  distin- 
guished from  the  more  bland,  so  called,  "  catarrhal "  (Volkmann)  inflamma- 
tions of  the  synovial  membrane,  due  to  tuberculosis  or  to  rheumatic  and 
gonorrhoeal  influences  ;  and  also  from  metastatic  suppuration  complicating 
pyaemia. 

It  is  generally  caused  by  infection  of  the  joint  from  without  through 
accidental  or  surgical  wounds,  or  by  its  invasion  of  a  suppurative  process 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  243 

establislied  in  the  vicinity,  as,  for  instance,  acute  osteomyelitis  or  a  subcu- 
taneous or  bursal  phlegmon.  Idiopathic  acute  sujipuration  of  the  knee- 
joint  is  very  rare  indeed. 

The  invasion  is  marked  by  one  or  more  sharp  chills,  very  high  fever, 
and  a  sudden  painful  intumescence  of  the  joint.  The  limb  is  rotated  out- 
ward, lying  on  its  outer  aspect,  is  flexed  at  an  obtuse  angle,  and  its  position 
is  carefully  maintained  by  the  patient,  as  the  constant  pain  is  terribly  in- 
tensified by  the  least  change  of  posture.  General  oedema  and  reddening  of 
the  integument  soon  follow,  the  septic  intoxication  frequently  producing 
delirium  and  a  typhoid  condition. 

The  intra-articular  tension  increasing,  perforation  of  the  capsule,  gener- 
ally upward  through  the  bursal  extension  of  the  joint  beneath  the  quadri- 
ceps tendon,  occurs,  and  is  marked  by  a  temporary  remission  of  the  in- 
tensity of  the  local  and  sometimes  of  the  general  symptoms.  One  or  more 
subfascial  or  subcutaneous  abscesses,  located  on  one  or  both  sides  of  the 
quadriceps,  appear,  and  rapidly  extend  upward  and  outward  until  perfora- 
tion of  the  skin  permits  the  escape  of  the  enormous  mass  of  pent-up  pus. 
Occasionally  the  matter  perforates  backward  into  the  poi^liteal  space,  this 
way  being  marked  out  by  the  bursae  situated  beneath  the  popliteus  muscle, 
which  are  frequently  in  open  communication  with  the  knee-joint.  In  this 
case  the  abscess  will  extend  downward  along  and  beneath  the  muscles  of  the 
calf. 

Spontaneous  perforation  will  not  bring  about  complete  and  lasting  relief, 
as  the  drainage  is  and  must  be  inadequate.  Profuse  suppuration  and  a  con- 
suming fever,  with  frequent  chills  and  colliquative  sweats,  will  in  a  short 
time  so  depress  the  patient's  condition,  that  amputation  will  have  to  be 
thought  of  as  the  last  resort  for  saving  life. 

The  treatment  should  be  that  of  deep-seated  phlegmon,  modified  by  the 
requirements  of  the  anatomical  peculiarities  of  the  knee-joint.  The  cavity 
of  the  knee-joint  naturally  consists  of  three  distinct  recesses :  one  below,  the 
other  above  the  patella ;  the  third  is  an  extension  of  the  suprapatellar  space, 
and  is  known  by  the  name  of  the  bursa  of  the  quadriceps.  In  flexion, 
where  the  knee-pan  is  firmly  held  down  to  the  condyles,  the  infra-  and 
supra-patellar  spaces  become  practically  non-communicating.  Andrews  of 
Chicago,  to  whom  we  owe  a  most  excellent  treatise  on  the  subject  of  injuries 
to  the  joints,  mentions  a  case*  of  traumatic  suppuration  of  the  infra- 
patellar recess  of  the  knee-joint,  where,  by  means  of  continued  flexion  and 
thorough  disinfection  and  drainage  of  the  same  space,  general  infection  of 
the  joint  was  effectually  prevented. 

To  effect  adequate  drainage  of  a  phlegmonous  knee-joint,  each  of  these 
recesses  must  be  separately  incised  and  drained. 

A  double  incision  of  each  of  these  spaces  will  be  much  more  effective 
than  a  single  one,  as  it  will  permit  more  thorough  irrigation.  In  very 
infectious  cases  two  additional  incisions  will  drain  away  pus  retained  in  the 
reflection  of  the  capsule  from  the  vicinity  of  the  crucial  ligaments. 

*  Ashhurst's  "  Encyclopedia  of  Surgery,"  vol.  iii,  p.  123. 


2U  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

The  first  incision  should  be  made  in  the  suprapatellar  space  on  the 
inner  side,  where  the  capsule  is  the  most  ample.  Haemorrhage  is  generally 
profuse,  hence  it  is  best  to  penetrate  the  tissues  gradually,  and  to  secure 
each  bleeding  vessel  as  soon  as  it  is  cut.  As  soon  as  the  joint  is  entered,  a 
dressing  forceps  is  thrust  through  it  to  the  corresponding  point  of  the  other 
side  of  the  joint,  where  the  second  incision  is  to  be  made  through  the  tissues 
raised  by  the  pressure  of  the  forceps.  The  point  of  the  forceps  emerging 
from  this  incision,  a  stout  drainage-tube  is  grasped  with  it,  and  drawn  into 
the  joint  just  far  enough  to  clear  the  synovial  membrane.  A  similar  piece 
of  drainage-tubing  is  inserted  into  the  first  incision,  and  the  protruding 
ends  of  the  tubes,  being  transfixed  with  safety-pins,  are  cut  off  on  a  level 
with  the  skin.  The  infrapatellar  and  submuscular  spaces  are  treated 
similarly,  and,  if  necessary,  the  lateral  pouches  of  the  joint  are  also  in- 
cised and  drained.  The  cavities  are  thoroughly  flushed  out  with  corrosive- 
sublimate  lotion,  a  large  moist  dressing  is  fastened  on,  and  the  limb  is 
secured  to  a  posterior  splint  to  insure  rest  and  painlessness  during  unavoid- 
able changes  of  posture  of  the  patient.  Wherever  perforation  of  the  capsule 
and  formation  of  a  circumarticular  abscess  has  occurred,  this  must  be  sepa- 
rately incised  and  drained. 

In  the  great  majority  of  cases,  resolute  and  comjDrehensive  measures  of 
this  kind  will  be  rewarded  by  prompt  improvement.  Daily  change  of  dress- 
ings and  irrigation  should  be  practiced  until  the  disapj)earance  of  all  the 
inflammatory  and  febrile  symptoms.  As  soon  as  the  discharges  become 
scanty  and  serous,  the  drainage-tubes  can  be  withdrawn  one  by  one.  Where 
the  affection  is  due  to  osteomyelitis,  anchylosis  will  result  as  a  rule,  espe- 
cially in  grown  individuals.  In  children,  prompt  and  adequate  drainage 
frequently  results  in  preservation  of  mobility. 

Case  I. — Charles  Hundertmark,  aged  four.  Acute  suppuration  of  knee-joint  caused 
by  a  blow  upon  head  of  tibia.  May  31,  1875. — Three  incisions — one  on  each  side  into 
the  suprapatellar  space,  a  third  one  into  the  quadi-iceps  bursa.  Daily  change  of  moist 
carbolized  dressings  and  irrigation.  Eapid  improvement.  June  iStJi. — Drainage  aban- 
doned.    July  4th. — Perfect  recovery  noted,  with  free  active  use  of  the  joint. 

Case  II. — John  S.,  grocer,  aged  nineteen.  Acute  suppuration  of  knee-joint,  with 
terrible  pain  and  typhoid  symptoms.  The  patient  was  brought  to  the  German  Hos- 
pital .lanuary  10,  1880,  by  Dr.  Schwedler,  who  administered  chloroform  during  the 
transfer,  to  allay  the  patient's  suffering  from  the  jolts  of  the  carriage.  Immediate  typi- 
cal multiple  incisions  and  drainage.  The  index-finger  detected  a  roughened  place  on 
the  articular  surface  of  the  inner  condyle  of  the  femur.  Undoubtedly  on  account  of 
the  osteomyelitic  process,  the  febrile  symptoms  receded  very  slowly.  Permanent  irri- 
gation of  the  joint  rendered  the  frequent,  terribly  painful  change  of  the  dressings 
unnecessary.  A  few  small  sequestra  belonging  to  the  cancellous  tissue  of  the  femoral 
epix)liysis  came  away  on  the  twenty-third  day.  Patient  was  discharged  cured,  March 
20th,  with  firm  anchylosis. 

In  exceptionaljy  neglected  cases,  where  the  process  has  assumed  the 
character  of  a  general  purulent  infiltration,  incisions  and  drainage,  supple- 
mented with  continuous  irrigation,  will  not  be  followed  by  as  prompt  im- 
provement as  is  desirable.     The  continued  high  fever,  the  formation  of 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  245 

new  abscesses,  will  certaiiily  bring  about  a  fatal  termination,  unless  the 
limb  is  amputated  clearly  beyond  the  limits  of  the  disease.  So-called  con- 
servative measures — as,  for  instance,  exsection  of  the  joint — are  entirely 
inadmissible  and  dangerous  under  these  circumstances.  They  will  fail  to 
remove  from  the  affected  parts  the  elements  of  contamination,  as  the  most 
rigid  antiseptic  measures  of  the  ordinary  kind  are  here  utterly  inadequate. 
The  phlegmonous  process  will  attack  the  newly-made  wound-surfaces,  and 
the  patient's  life  will  be  placed  in  the  greatest  jeopardy  by  secondary  haemor- 
rhage.    The  following  case  forcibly  illustrates  the  weight  of  these  remarks : 

Case. — Max  Loflfmann,  butcher,  aged  twenty.  Admitted,  October  25,  1885,  to 
Mount  Sinai  Hospital.  October  12th. — The  submuscular  recess  of  the  knee-joint  was 
accidentally  incised  with  a  filthy  butcher's  knife.  Some  synovia  escaped  from  the 
small  puncture ;  after  the  accident  the  patient  walked  home.  Suppuration  of  the  knee- 
joint  set  in  the  following  day,  with  rigors  and  general  dejection.  The  wound  was 
dressed  by  a  Jersey  City  practitioner  with  an  adhesive-plaster  dressing  placed  over  the 
incision.  The  patient  was  admitted  to  the  hospital  in  a  highly  septic  condition,  large 
quantities  of  thin,  ichorous  pus  escaping  from  the  joint  on  slight  pressure.  Immedi- 
ately the  patient  was  anaesthetized,  and  typical  incision  and  drainage  were  done.  The 
synovial  lining  of  the  joint  was  coated  with  a  greenish-gray  adherent  and  putrid  mem- 
brane, in  looks  identical  with  the  membranous  coating  in  pharyngeal  diphtheria.  A 
number  of  small,  purulent  foci  were  opened  by  the  incisions  made  for  drainage  of  the 
joint.  A  moist  dressing  and  dorsal  splint  were  applied.  In  spite  of  frequent  irriga- 
tion, no  remission  of  the  high  fever  or  local  pain  following,  amputation  of  the  thigh 
was  proposed,  in  view  of  the  visible  failing  of  the  patient's  strength.  This,  however, 
was  resolutely  declined  by  the  patient  and  his  widowed  mother,  who  begged  for  an 
attempt  to  save  the  limb.  The  author,  against  his  better  judgment,  performed  exsec- 
tion of  the  knee-joint,  November  6th.  Esraarch's  band  was  applied  to  the  upper  third 
of  the  thigh  without  the  previous  use  of  the  elastic  roller  bandage,  and  a  continuous 
stream  of  corrosive-sublimate  lotion  (1  :  1,000)  was  kept  playing  upon  the  wound  during 
the  entire  operation,  which  was  rapidly  but  carefully  performed.  Care  was  taken  to 
operate  in  healthy  parts,  and  all  the  involved  tissues  were  removed.  The  wound 
was  drained  and  closed  in  the  usual  manner,  and  the  dressed  limb  was  fixed  upon 
a  dorsal  splint.  Suppuration  of  the  wound  followed,  requiring  frequent  changes 
of  dressing  and  irrigation,  the  secretions  retaining  all  the  while  their  peculiar  thin, 
ichorous  character  noted  from  the  outset.  On  the  afternoon  of  November  18th,  pro- 
fuse arterial  hasmorrhage  occurred  from  the  wound,  which  was  temporarily  checked 
by  the  house-surgeon  with  the  application  of  Esmarch's  band.  Being  hastily  sum- 
moned to  the  hospital,  the  author  found  the  patient  blanched  and  collapsed.  About 
twenty  ounces  of  a  6  :  1,000  watery  solution  of  cooking  salt  were  transfused  into  his 
median  vein,  and  resulted  in  a  notable  improvement  of  the  pulse.  Amputation  of  the 
thigh  was  quickly  done  as  a  last  resort.  The  patient,  however,  expired  before  the 
removal  of  Esmarch's  band. 

Post-mortem  examination  revealed  a  sieve-like  perforation  of  the  popliteal  vein 
and  a  large  oblong  defect  of  the  popliteal  artery,  both  of  which  were  found  expo:fed 
and  surrounded  by  a  massive  blood-clot.  The  walls  of  the  cavity  containing  the  clot 
consisted  of  broken-down  and  necrosed  tissues. 

There  is  little  doubt  that  an  early  amputation  might  have  saved  the  patient's  life. 

(e)   SuppuEATiojsr  of  the  Inguiistal  Glands. — Two  groups  of  lym- 
phatic glands  have  to  be  distinguished  iu  the  inguinal  region — one  situated 
33 


■24:6  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

below  Poupart's  ligament,  the  other  above  it.  The  subinguinal  group  is- 
frequently  the  seat  of  phlegmonous  inflammation,  due  to  absorption  of  sep- 
tic material  from  sores  caused  by  the  pressure  of  ill-fitting  shoes,  ulcerated, 
bunions,  ingrowing  toe-nail,  and  excoriations  of  the  lower  extremity  from 
scratching  in  eczema.  Their  treatment  by  incision  does  not  require  special 
elucidation. 

Should,  however,  their  excision  become  necessary,  the  rules  laid  down 
for  the  removal  of  tumors  from  Scarpa's  triangle  (pages  50  and  53)  should 
be  heeded. 

Acute  suppuration  of  the  supi'ainguinal  glands  is  caused  most  generally 
by  ulcerative  or  suppurating  processes  of  the  generative  organs.  Their 
treatment  is  subject  to  the  principles  accepted  for  glandular  abscesses  of  other 
regions,  and  may  be  dismissed  with  the  remark  that  the  hest  way  to  incise 
them  is  not  imrallel,  hut  at  a  right  angle  loith  the  direction  of  the  fibers  of 
Pouparfs  ligament.  The  edges  of  the  incision  will  gap  asunder,  and  afford, 
very  good  drainage  even  without  the  use  of  a  tube,  and,  later  on,  the  edges 
of  the  cut  will  not  exhibit  the  tendency  to  become  inverted,  which  is  the 
source  of  much  trouble  in  the  after-treatment. 

Interminable  chronic  suppuration  of  the  suprainguinal  glands  fre- 
quently indicates  their  bodily  extirpation.  The  safest  way  of  accomplishing 
their  removal  is  as  follows  :  Two  semi-elliptic  incisions  should  include  all 
the  fistulous  openings  leading  into  the  glandular  swelling.  They  should 
be  gradually  deepened  until  a  comparatively  healthy  part  of  the  swelling  is 
exposed.  Here  the  capsule  is  incised,  and  the  mass  is  carefully  dissected 
out  with  the  tip  of  a  pointed  scalpel.  Blunt  dissection  should  be  resorted 
to  only  where  it  is  evidently  easy,  as  in  using  much  blunt  force  the  glands 
may  be  ruptured,  and  their  contents  soil  the  wound. 

This  injunction  is  important,  as  intentional  or  unintentional  injury 
to  the  'peritonmum  may  become  unavoidable.  Should  the  epigastric  vessels 
be  in  the  way,  they  must  be  cut  and  deligated.  Attention  ought  to  be  paid 
also  to  the  seminal  cord,  which  occasionally  enters  into  very  close  relations 
with  inguinal  glandular  swellings. 

/.  Perityphlitic  Abscess : 

Arrangement  of  Connective- Tissue  Planes  of  the  Pelvis. — The  extension  of  acute 
or  chronic  suppurative  processes,  originating  in  or  near  the  pelvis,  is  prescribed  by  the 
anatomical  arrangement  of  tlie  peritonaeum  and  fasciae.  This  circumstance  is  the  cause 
of  the  typical  spread  and  outward  perforation  of  pelvic  abscesses. 

On  account  of  practical  reasons,  three  groups  of  pelvic  abscesses  deserve  special 
distinction : 

1.  All  retro-peritoneal  supinirations  have  the  tendency  to  dissect  up  the  anterior 
reflection  of  the  peritonaeum.  A  fluctuating  swelling  is  apt  to  appear  above  and  cor- 
responding to  the  inner  two  thirds  of  Poupart's  ligament.  Perimetritic  and  peri- 
typhlitic abscesses  belong  to  this  group. 

2.  The  second  group  is  composed  of  purulent  accumulations  that  extend  heneath  the 
fascia  inclosing  the  psoas  muscle.  They  generally  leave  the  pelvis  by  the  aperture  be- 
low Poupart's  ligament,  through  which  the  ilio-psoas  muscle  emerges,  and  appear  on 
the  front  of  the  thigh  along  the  sides  of  the  quadriceps.     Their  appearance  is  generally 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  247 

accepted  as  an  indication  of  the  situation  of  tlie  source  of  the  suppurative  process  near 
the  lower  thoracic,  or  the  lumbar  vertebrte. 

3.  The  tMrd  group  consists  of  abscesses  that  take  their  origin  within  the  boundaries 
of  the  iliacus  muscle,  which  occupies  the  internal  aspect  of  the  os  ilium.  Their  exten- 
sion is  prescribed  by  the  limits  of  the  iliacus,  and  they  commonly  appear  on  the  surface 
below  the  anterior  superior  spine  of  the  ilium,  or  more  rarely  in  the  loin  at  the  exter- 
nal margin  of  the  quadratus  luiiiborum.  The  abscesses  pointing  helow  the  anterior 
superior  spine  have  no  peritoneal  investment,  and  can  be  freely  incised  without  fear  of 
injuring  the  peritonaeum. 

To  sum  up  briefly,  we  may  say  that  retro-peritoneal  abscesses,  as,  for  instance,  pei'i- 
typhlitic  or  perimetritic  gatherings,  will  generally  point  above  and  corresponding  to  the 
inner  two  thirds  of  Poupart's  ligament. 

Psoas  abscess,  indicating  affections  located  on  the  front  part  of  the  thoracic  or  lum- 
bar vertebras,  will  extend  below  Poupart's  ligament  to  the  front  of  the  thigh. 

Iliacal  abscesses,  caused  by  suppurative  aflfections  of  the  os  ilium,  the  sacro-iliac 
symphysis,  or  the  sacrum,  will  generally  point  below  the  anterior  superior  spine  of  the 
ilium,  occupying  the  outer  third  of  the  space  above  Poupart's  ligament.  Occasion- 
ally they  will  point  in  the  lumbar  or  gluteal  region,  or,  when  the  abscess  is  very  great, 
in  two  or  all  of  the  regions  indicated. 

Inflammatory  or  ulcerative  affections  of  the  mucous  membrane  of  the 
caecum  or  vermiform  appendix,  mostly  due  to  fecal  impaction  or  the  j^res- 
ence  of  foreign  bodies,  are  often  followed  by  phlegmonous  processes  estab- 
lished in  the  retro-peritoneal  connective  tissue  located  just  behind  the  thick 
gut.  Occasionally,  but  on  the  whole  rarely,  similar  jorocesses  obtain  on  the 
left  side  of  the  abdomen,  in  the  connective  tissue  behind  the  descending 
colon. 

Most  commonly  during  adolescence  a  deep-seated,  painful  tumor  de- 
velops in  tlie  iliac  fossa,  with  more  or  less  high  fever,  and  gradually  ex- 
tends to  the  groin.  As  the  process  approaches  the  surface,  oedema  of  the 
integument  and  fluctuation  appear.  With  very  few  exceptions  the  gathering 
is  retro-peritoneal,  and  works  its  way  outward  along  the  posterior  surface  of 
the  peritonaeum  till  it  reaches  to  the  anterior  reflection  of  this  membrane 
on  a  level  of  Poupart's  ligament,  where  it  becomes  subfascial  and  subcutane- 
ous. This  dissecting  up  of  the  peritonseum  by  the  abscess  will  assume  very 
extensive  proportions  if  the  tension  remains  unrelieved  for  a  long  time. 
The  author  has  observed  burrowing  of  a  perityphlitic  abscess  into  the  pre- 
A^esical  connective-tissue  space  (case  of  Henry  Marks). 

The  danger  of  perforation  of  a  perityphlitic  abscess  into  the  unaffected 
part  of  the  peritoneal  cavity  is  present,  but  on  the  whole  not  very  great. 
Only  one  case  of  this  kind  came  under  observation. 

Case. — H.  D.,  clerk,  aged  twenty.  Subject  to  alvine  sluggishness,  contracted,  after 
a  more  than  usually  severe  spell  of  constipation,  a  deep-seated,  hard,  painful,  peri- 
typhlitic swelling.  Cathartics  failed  to  relieve  the  bowels,  and,  high  fever  with  vomit- 
ing having  set  in,  the  author  was  consulted.  May  1,  1878. — Typical  swelling  of  a 
cylindrical  shape  was  made  out  in  the  right  groin,  and  a  number  of  repeated  large  in- 
jections of  tepid  water  into  the  gut  were  employed  without  success.  May  3d. — The 
peritoneal  symptoms,  notably  vomiting,  became  very  distressing,  wherefore  this  therapy 
was  abandoned  and  opium  treatment  begun.     At  the  same  time  an  ice-bag  was  placed 


248 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  183. — IneisiDg  peritypbilitic  abscess. 


over  the  swelling.  The  change  eftected  a  decided  improvement  in  the  subjective  symp- 
toms, but  the  swelling  continued  to  increase  and  the  fever  remained  unrelieved.  May 
17th. — Spontaneous  evacuation  of  a  large,  formed  stool  occurred.  May  19th. — The 
general  condition  becoming  very  poor,  incision  was  urged,  but  was  firmly  declined  by 
patient  and  parents.  Suddenly,  in  the  night  of  the  same  day,  perforative  symptoms 
developed.     The  patient  died,  May  20th,  of  septic  peritonitis. 

Post-mortem  examination  demonstrat- 
ed an  internal  perforation  of  the  abscess, 
and  putrid  septic  peritonitis.  Had  the 
patient  consented  to  the  operation,  the 
case  might  have  turned  out  diiferently. 
Perforation  took  place  on  the  nineteenth 
day  after  the  invasion. 

The  danger  of  perforation  lias 
been  much  exaggerated.  It  is  very 
unlikely  to  occur  in  the  early  stages 
of  the  disease.  Its  exaggeration  has 
frequently  led  to  hasty  operations, 
injury  of  the  peritonaeum  with  its 
contamination  by  the  escaping  fetid 
pus,  and  fatal  general  peritonitis.  The  practice  of  searching  for  pus  with  a 
hollow  needle  in  the  first  three  or  four  days  of  the  disorder  is  also  fraught 
with  danger.  The  abscess  not  having  pushed  up  and  out  of  the  way  the 
peritoneal  reflection,  this  may  be  doubly  perforated  by  the  instrument. 
Hilton-Eoser's  method  is  also  unsafe  in  the  early  stages  of  perityphlitic  or 
retrocolic  abscess  for  the  same  reasons. 

Case. — Francisca  Bertrand,  aged  forty-five.  Was  taken  ill  with  fever  early  in 
July,  1882,  and  developed  a  deep-seated,  painful  swelling  in  the  left  iliac  fossa,  with 
high  fever  and  peritonitic  symptoms.  On  the  afternoon  of  August  5th,  probatory 
puncture  brought  out  some  pus,  wherefore,  with  the  aid  of  the  family  physician,  Dr. 
Assenheimer,  incision  was  practiced  by  Hilton's  method.  A  large  quantity  of  pus 
escaped,  and  a  drainage-tube  and  antiseptic  dressing  were  applied.  In  the  following 
night  very  acute  peritonitis  set  in,  to  which  the  patient  succumbed  August  6th.  No 
doubt  the  reflection  of  the  peritonaeum  was  injured,  and  part  of  the  pus  must  have 
entered  the  peritoneal  cavity. 

Where  symptoms  of  special  urgency  seem  to  indicate  early  interference, 
the  approach  of  the  abscess  has  always  to  be  made  by  gradual  and  careful 
dissection,  layer  by  layer,  just  as  for  deligation  of  the  external  iliac  artery. 
The  reflection  of  the  peritonaeum  must  be  found,  carefully  raised,  and  held 
aside.  After  this  a  probatory  puncture,  made  in  the  bottom  of  the  wound, 
will  be  safe,  and,  pus  being  found,  a  vent  for  the  escape  of  pus  by  Hilton- 
Eoser's  method  may  yield  satisfactory  results. 

To  sum  up,  it  may  be  said  that  incision  is  most  dangerous  at  that  stage 
of  the  development  of  the  abscess  when  the  peritonseum  has  become  infil- 
trated, but  is  not  yet  raised  up  and  pushed  away  from  the  abdominal  wall 
by  the  contents  of  the  abscess.  This  generally  is  the  case  on  from  the 
fourth  to  tlie  seventh  day.     Before  this,  dissection  and  recognition  of  the 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  249 

peritonfeum  are  easy,  but  in  many  cases  may  be  unnecessary,  hence  can  not 
be  commended. 

The  safest  way  is  to  wait  till  the  eighth  or  tenth  day,  or  until  fluctua- 
tion is  evident,  when  the  peritoneum  is  well  raised  up,  and  the  danger  of 
its  injury  very  remote. 

Case. — Jack  Schlosser,  aged  ten.  Had  an  attack  of  typhlitis  in  November,  1885, 
from  wliich  he  promptly  recovered.  June  4,  1886. — Perityphlitis  was  again  diagnosti- 
cated by  Dr.  Koehler,  and,  under  the  administration  of  mild  laxatives  and  enemata,  the 
condition  of  things  seemed  to  improved  up  to  the  10th,  when  higher  febrile  symptoms 
set  in,  and  the  area  of  painful  intumescence  in  the  right  groin  became  notably  en- 
larged. June  13th. — The  diagnosis  of  abscess  was  made  out.  June  ll^th. — The  author 
incised  and  drained  the  cavity  with  the  aid  of  Dr.  Koehler,  under  whose  care  the  case 
improved  rapidly,  and  was  cured  June  30th. 

Digital  exploration  of  the  cavity  is  very  advisable,  for  two  reasons  :  First, 
it  will  lead  to  easy  detection  and  removal  of  foreign  bodies,  as,  for  instance, 
kernels  or  stones  contained  in  the  bottom  of  the  abscess  ;  and,  secondly,  it 
will  enable  the  surgeon  to  form  a  just  conception  of  the  extent  and  direction 
of  burrowing  sinuses,  which  may  require  separate  drainage. 

Case. — Henry  Marks,  aged  seventeen,  suffered  from  habitual  constipation  and  fre- 
quent attacks  of  colic.  In  June,  July,  and  August,  1878,  severe  attacks  of  colic  were 
noted  and  overcome  by  the  use  of  purgatives.  August  25th. — Dr.  L.  Weiss,  the  family 
attendant,  made  out  typhlitis  and  ordered  a  laxative,  which,  however,  failed  to  relieve 
the  patient.  Thereupon  opium  was  methodically  exhibited  until  September  6th,  when 
the  patient  had  a  spontaneous  and  copious,  formed  evacuation.  September  7th. — The 
temperature  rose  to  104°  Fahr.,  the  external  swelling  in  the  right  groin  became  very 
marked.  September  10th. — The  author  saw  the  patient  in  consultation  with  Dr.  Weiss. 
A  uniform  puffy  swelling  was  found  occupying  the  right  groin,  and  was  extending 
beyond  the  median  line  of  the  abdomen.  Frequent  urination  distressed  the  patient  a 
good  deal,  who  exhibited  the  usual  hectic  symptoms  of  long-continued  suppuration. 
Deep  fluctuation  was  made  out,  and  evacuation  of  the  abscess  was  determined  upon. 
The  transversalis  fascia  being  gradually  exposed,  it  was  found  infiltrated  and  firmly 
attached  to  the  underlying  tissues.  A  probatory  puncture  made  in  the  bottom  of  the 
wound,  close  to  the  os  ilium,  gave  pus,  whereupon  the  abscess  was  freely  incised,  and 
a  large  quantity  of  matter  was  voided.  No  foreign  body  could  be  foimd.  Digital 
exploration  demonstrated  a  long  sinuosity  extending  toward  the  median  line  to  a  pocket 
occupying  the  prevesical  space.  A  drainage-tube  was  placed  into  the  main  abscess, 
and  another  one  was  carried  into  the  prevesical  space,  and  the  wound  was  dressed  with 
carbolized  gauze.  The  patient's  wretched  condition  at  once  commenced  to  improve ; 
appetite  and  sleep  returned,  and  the  profuse  night-sweats  disappeared.  September 
20th. — The  drainage-tubes  became  disarranged,  and  were  found  slipped  out  of  the 
wound.  DiflBculty  was  experienced  in  replacing  them,  and  symptoms  of  retention, 
with  renewed  pain  and  fever,  set  in  again.  September  23d. — The  author  again  saw  the 
patient,  and  replaced  the  tubes.  A  considerable  quantity  of  pus  was  found  in  the  pre- 
vesical pocket.  From  this  date  on  uninterrupted  improvement  was  noted,  and  the 
patient  got  up  October  10th.  October  20th,  the  tubes  were  withdrawn,  and  October 
30th  the  fistula  was  closed. 

As  previously  mentioned,  stercoral  ulceration  of  the  intestinal  mucous 
membrane  is  the  most  common  cause  of  perityphlitic  abscess.     This  impac- 


250  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURQERY. 

tion  of  faeces  is  ordinarily  located  in  the  caecum  or  in  the  vermiform  appen- 
dix. But  occasionally,  where  a  cancerous  stricture  of  the  ileo-csecal  valve 
is  present,  it  will  be  found  located  in  the  lowest  part  of  the  ilium,  causing 
great  distention,  ulceration,  adhesive  attachment,  and  perforation  into  the 
retro-colic  connective-tissue  space,  simulating  perityphlitic  abscess. 

Case. — Mr.  M.  G.,  aged  sixty-two,  had  been  suffering  from  habitual  and  very  obsti- 
nate constipation  for  years.  In  May,  1880,  profuse  diarrhoea  set  in,  and  could  not  be 
controlled  by  any  of  the  usual  dietary  and  therapeutic  measures.  A  grave  deterioration 
of  the  general  condition  developed,  and  the  patient  lost  very  much  flesh  in  spite  of 
forced  feeding.  August  31st. — Fever  set  in,  and  the  presence  of  a  painful  swelling  in 
the  iliac  fossa  was  made  out.  September  3d. — The  author  saw  the  case  in  consultation 
with  Dr.  W.  Balser  and  Dr.  L.  Conrad.  A  large  fluctuating  swelling  occupied  the 
right  half  of  the  pelvis,  and  tympanitic  percussion  sound  was  noted  in  the  lumbar 
region.  Two  incisions  were  made — one  above  Poupart's  ligament,  another  in  the 
lumbar  region — and  an  enormous  amount  of  gas,  pus,  and  fecal  matter  was  evacuated. 
Profuse  secretion  and  diarrhoea  continued,  and  the  patient  died  September  22d.  Post- 
mortem exam,ination  revealed  a  tight  cancerous  stricture  of  the  ileo-csecal  valve,  and  an 
enormous  dilatation  of  the  lower  portion  of  the  ilium,  which  resembled  thick  gut. 
Large  masses  of  impacted  fecal  matter  were  found  in  this  pouch,  which  was  adherent 
to  the  posterior  pai-ietal  peritonaeum,  and  was  freely  communicating  through  a  number 
of  ulcerous  defects  with  the  abscess  cavity. 

Flexion  of  the  thigh  upon  the  pelvis  is  a  very  constant  symptom  of  i)eri- 
typhlitic  abscess,  and  is  in  children  occasionally  the  cause  of  an  erroneous 
diagnosis  of  hip-joint  disease.  But  hip-Joint  disease  may  undoubtedly  be 
caused  by  the  extension  of  a  perityphlitic  abscess  along  the  ilio-psoas  muscle 
to  the  iliac  bursa,  and  hence  into  the  hip-joint. 

Case.— Ernestine  S.,  servant-girl,  aged  nineteen,  admitted  March  2,  1880,  to  the 
German  Hospital,  with  the  diagnosis  of  hip-joint  disease,  the  symptoms  of  which  were 
indubitably  present.  Emaciating  fever,  and  the  characteristic  flexion  and  adduction 
of  the  thigh,  together  with  swelling  of  the  gluteal  and  infrapubic  regions,  seemed  to 
admit  of  no  doubt.  Examination  under  ether,  however,  revealed  a  fluctuating  swelling 
of  the  right  groin,  which  yielded  pus  on  puncture,  and  was  incised.  A  large  quantity 
of  pus  and  the  stem  of  an  apple  or  pear  were  evacuated.  Another  incision  below 
Poupart's  ligament  established  drainage  of  an  abscess  communicating  with  the  peri- 
typhlitic gathering.  The  lower  extremity  was  put  into  Buck's  extension,  and  the 
cavities  were  daily  irrigated.  Operative  measures,  directed  against  the  profuse  dis- 
charge from  the  lower  incision — that  is,  drainage  or  exsection  of  the  hip-joint^  were 
contemplated,  when  the  girl  contracted  erysipelas,  and  died  of  it  in  May,  1880.  Post- 
mortem examination  established  the  fact  of  hip-joint  suppuration,  a  communication  of 
the  perityphlitic  abscess  with  the  joint  being  found,  by  way  of  the  iliac  bursa. 

Of  sixteen  cases  of  perityphlitic  or  retro-colic  abscess  observed  by  the 
author,  fifteen  were  operated  on,  and  twelve  recovered. 

Three  died — one  of  septic  peritonitis,  due  to  injury  and  infection  of  the 
peritonaeum  at  the  time  of  the  operation  ;  one  from  exliaustion,  due  to 
cancer  of  the  ilco-caecal  valve  and  ulcerative  enteritis  ;  and  one,  complicated 
by  hip-Joint  suppuration,  from  erysipelas. 

One  case  was  not  operated  on,  and  died  of  septic  peritonitis  caused  by 
perforation  of  the  abscess  into  the  peritoneal  cavity. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON.  251 

Four  more  cases  of  perityphlitic  inflammation,  not  operated  on,  but 
treated  with  opium  and  large  enemata,  recovered.  In  two  of  these  marked 
tendency  to  relapses  and  habitual  constipation  persist. 

g.  Abscess  of  the  Liver. — The  diagnosis  of  hepatic  abscess  is  based 
upon  the  presence  of  a  painful  and  growing  intumescence  of  the  liver,  ac- 
companied by  more  or  less  intense  fever,  which  gradually  assumes  a  hectic 
character.  In  the  beginning  the  swelling  ascends  and  descends  at  respira- 
tion ;  but  later  on,  when  the  liver  becomes  attached  to  the  abdominal  wall, 
this  mobility  disappears.  Probatory  puncture  with  a  fine  aspirating  needle 
can  be  safely  made,  and  will  generally  dispel  any  doubt.  As  soon  as  the 
diagnosis  is  secured,  incision  has  to  be  made. 

Where  adhesion  of  the  hepatic  swelling  to  the  abdominal  wall  is  estab- 
lished, or,  even  more  so,  where  the  suppurative  process  has  involved  the 
integument,  a  free  incision  can  be  safely  made.  A  large-sized  drainage-tube 
should  be  inserted  into  the  cavity,  and  frequent  irrigation  should  be  em- 
ployed.    The  wound  is  covered  with  an  ample  moist  dressing. 

The  incision  of  hepatic  abscesses  located  in  the  unattached  liver  require 
some  special  precautions.  The  abdominal  wall  opposite  the  tumor  is  incised 
under  a  strict  observance  of  the  rules  laid  down  for  laparotomy,  so  as  to 
expose  the  liver.  The  incision  is  packed  with  iodoformed  gauze,  and  a  dry 
dressing  is  applied. 

In  three  days  firm  adhesions  of  the  liver  to  the  abdominal  wall  will  be 
established,  when,  the  packing  being  removed,  the  liver  is  punctured,  and, 
pus  being  found,  is  freely  incised  and  the  cavity  evacuated  and  drained. 

Ji.  Lumbar  Abscesses. — The  significance  of  acute  lumbar  abscesses  de- 
pends upon  their  causation  and  upon  the  locality  from  which  they  take 
their  origin.  The  majority  of  lumbar  abscesses  are  caused  by  purulent 
affections  of  the  kidney  or  its  pelvis — as,  for  instance,  by  renal  calculus 
or  pyelitis — but  in  a  comparatively  large  number  of  cases  no  affection  of  the 
kidneys  or  their  adnexa  can  be  recognized,  and  traumatism  of  one  or  another 
kind  must  be  assumed  as  the  causative  agent. 

Contusion  and  a  sudden  and  unexpected  strain  of  the  back  were  stated 
to  the  author  by  patients  as  causative  factors.  The  beginnings  of  lumbar 
abscess  are  always  obscure  and  insidious.  A  deep-seated  unilateral  pain  in 
the  small  of  the  back  is  first  complained  of.  One  or  more  chills  or  a  low 
form  of  hectic  fever  set  in.  The  patient's  back  is  bent  upon  the  affected 
side,  and  is  more  or  less  tender.  Loss  of  vigor  and  emaciation  become  more 
and  more  evident,  until  a  distinct  tumor,  marked  by  dullness  on  percussion, 
can  be  made  out  in  the  space  between  the  crest  of  the  ilium  and  the  twelfth 
rib.  The  way  of  extension  of  the  abscess  is  prescribed  by  the  quadratus 
lumborum  muscle,  the  outer  edge  of  which  serves  as  a  landmark  for  finding 
and  incising  it.  The  presence  of  pyelitis  or  pyonephrosis,  ascertained  by 
examination  of  the  urine,  is  very  significant,  and  possible  doubts  as  regards 
the  nature  of  the  trouble  may  be  dispelled  by  one  or  more  probatory  punct- 
ures with  a  well-disinfected  hollow  needle  and  the  aspirator.  A  good-sized 
caliber  should  be  selected,  as  grumous  or  flocculent  pus  is  apt  to  clog  a 


252 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  184. — Lange's  position  for  renal  and  perirenal 
operations. 


small-sized  needle,  aud  a  negative  result  may  be  arrived  at  in  the  presence 
of  a  large  collection  of  matter. 

Case. — Mr.  I.  A.,  brewer,  aged  twenty-two,  developed  lumbar  pain  and  swelling 
of  the  right  side  without  any  known  cause.  Aponl  17,  1881. — High  fever  accompanied 
the  seizure,  and,  though  no  fluctuation  could  be  felt,  the  diagnosis  of  perinephritic 
abscess  was  made.  April  21st. — In  the  presence  of  Dr.  Heppenheimer,  the  family  phy- 
sician, four  probatory  punctures  were  made  with  an  aspirator  needle  without  positive 
result,  and,  unfortunately,  the  contemplated  incision  was  deferred  until  the  next  day, 
when  perforation  into  the  pleura  and  rapidly  fatal  pyothorax  developed. 

Had  a  larger-sized  needle 
been  used,  pus  would  have 
been  found,  and  the  fatal 
termination  might  have  been 
averted  by  timely  incision. 

Early  incision  can  never 
do  any  harm  where  perine- 
phritic abscess  is  suspected, 
and  will  be  of  some  use  even 
if  pus  be  not  found  at  the 
first  attempt.  On  account 
of  the  deep  situation  of  the 
abscess,  and  the  necessity  of 
exploring  its  interior  for  sinuosities,  which  may  require  separate  drainage, 
an  ample  incision  is  advisable.  It  should  be  done  in  ansesthesia  under 
strict  antiseptic  precautions,  and  by  gradual  dissection. 

The  patient  is  brought  into  the  position  recommended  by  Dr.  F.  Lange 
for  nephrotomy.  A  roll  made  of  a  blanket  is  slipped  under  the  lumbar  re- 
gion, and  the  body  is  placed  semi-prone 
upon  the  affected  side,  as  shown  in  the 
accompanying  cut  (Fig.  184).  The  vicin- 
ity of  the  swelling  is  carefully  cleansed  and 
disinfected,  and  the  surrounding  parts  of 
the  body  are  protected  with  rubber  cloths 
and  towels  in  the  usual  manner.  A  lon- 
gitudinal incision  two  or  three  inches  in 
length  is  made,  commencing  about  an  inch 
below  the  last  rib,  and  extending  to  near 
the  crest  of  the  ilium,  and  is  gradually 
deepened  until  the  abdominal  muscles  are 
all  divided.  Frequently  pus  will  be  reached 
before  the  edge  of  the  quadratus  lumborum 
muscle  is  exposed.  Should  this  not  be  the 
case,  a  grooved  director  may  be  inserted  un- 
derneath the  external  margin  of  this  muscle, 

and,  being  pushed  downward  and  toward  the  median  line,  will  soon  enter  the 
abscess.     As  soon  as  pus  is  seen  to  a^opear  in  the  groove  of  the  instrument. 


Fig.  185. — Ineisiiijr  perinephritic 
abscess. 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


253 


Fig.  186. — Arrangement  of  drainage-tubes  for  perinephritic  or  any- 
other  deep-seated  and  large  abscess  cavity. 


a  dressing-forceps  is  insinuated  into  the  cavity,  and  is  withdrawn  while  held 
wide  open.  Blunt  dilatation  of  this  kind  can  be  repeatedly  practiced  until 
the  aperture  is  large  enough  to  admit  the  index-finger  for  exploration. 

Should  the  abscess  contain  urinous  matter  or  stones,  or  should  the  septa 
of  the  calices  of  the  renal  pelvis  be  recognized  by  touch,  the  causation  of 
the  process  by  perforation  outward  from  a  suppurating  kidney  will  suffer 
no  doubt.  If  found,  stones  may  be  then  extracted,  and  the  cavity,  being 
well  washed  with  boro-salicylic  lotion,  is  drained  by  the  insertion  of  one  or 
more  stout  rubber  tubes. 

Note. — A  very  efficient  mode  of  draining  is  the  following  one :  A  number  of  fenestra  are 
cut  into  the  sides  of  a  large-calibered  rubber  tube,  which  is  placed  well  within  the  cavity.  An- 
other smaller-sized  tube  of 
the  same  length  is  pro- 
vided with  a  couple  of 
fenestra  near  its  mesial 
end,  and  is  inserted  into 
the  abscess  alongside  of 
the  larger  tube  (Fig.  186). 
A  stream  of  lotion  inject- 
ed into  the  smaller  tube 
will  enter  the  bottom  of 
the  abscess,  will  wash  out 
its  recesses,  and  will  carry 
away  secretions  and  debris 

through  the  many  fenestra  of  the  larger  tube.  Safety-pins  thrust  through  the  distal  ends  of  the 
tubes  will  prevent  their  being  lost  in  the  abscess.  An  ample  antiseptic  moist  dressing  should 
envelop  the  entire  lumbar  region,  and  the  patient  should  be  brought  to  bed. 

In  opening  perinephritic  abscesses,  the  author  has  met  with  two  cases 
in  which  the  pus  had  a  peculiar  whitish-yellow  color,  the  consistency  of 
curdled  cream,  and  the  odor  of  freshly-made  warm  whey.  In  both  of  these 
cases  death  caused  by  uremia  followed  some  time  after  the  incision,  and 
post-mortem  examination  showed  that  the  parenchyma  of  the  kidney  had 
been  destroyed,  and  that  the  organ  was  a  pus-bag  with  fibrous  walls,  which 
were  perforated  and  communicating  with  a  number  of  secondary  abscesses 
located  in  the  pelvis.     The  secretions  contained  tubercle  bacilli. 

Case. — Emil  Oohn,  clerk,  aged  thirty.  Pyelonephritis  of  many  years'  standing.  Very 
marked  anaemia  and  high  fever,  with  a  large  lumbar  and  pelvic  swelling,  that  was  first 
noted  in  February,  1886.  Incision,  done  April  28, 1886,  at  the  German  Hospital,  evacu- 
ated an  enormous  amount  of  the  above-mentioned  peculiar  smelling  pus.  The  tempera- 
ture was  at  once  reduced  to  nearly  the  normal  standard.  As  the  cavity  contracted,  and 
the  secretion  became  scanty,  the  house-surgeon  withdrew  the  tube,  whereupon  retention 
in  the  pelvic  part  of  the  abscess  with  renewed  fever  compelled.  May  15th,  dilatation 
and  replacement  of  the  tubes.  The  evacuation  of  the  abscess  was  not  followed  by  an 
improvement  of  the  quality  of  the  urine,  which  continued  to  contain  pus  and  hyaline 
casts,  showing  that  the  other  kidney  was  also  affected.    Death  from  uraemia,  May  10th. 

Cases  of  surgical  kidney  may  get  cured  after  the  extraction  of  stones,  if 
portions  of  the  renal  parenchyma  be  preserved,  and  continue  to  secrete 
urine,  and  the  ureter  be  unobstructed  by  calculi  or  cicatricial  stenosis. 
34 


BsBh   -J 

^ 

fti^  JH 

■254  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Should  the  latter  conditions  prevail,  a  urine  fistula  will  persist,  and  removal 

of  the  kidney  may  come  in  question. 

In  cases  where  the  kidney  has  lost  its  identity,  but  no  complicated  and 

unfavorable  topographical  conditions  of  the  abscess  cavity  are  present,  a 

cure   may  also   follow  incision 
and  drainage. 

Where  the  relations  of  the 
abscess  are  unfavorable — that 
is,  the  kidney  consists  of  a 
number  of  communicating  or 
separate  abscesses — debilitating 
suppuration  may  baffle  the  ef- 
forts of  the  surgeon  for  a  long 

Fis.  187.— Dressing  for  lumlwxr  or  hepatic  abscess.         time.       It   is  best   in    theSC  CaSCS 

to  await  the  contraction  of  the 
walls  of  the  main  abscess  of  the  kidney  before  proceeding  to  the  extirpa- 
tion of  the  organ. 

Lumbar  abscesses,  the  relation  of  which  to  purulent  affections  of  the 
kidneys  is  unlikely  or  doubtlessly  absent,  admit  of  a  much  better  prognosis. 
They  are  frequently  referred  by  the  patients  to  traumatisms,  and,  properly 
incised,  heal  very  promptly. 

Case. — A.  F.,  pawnbroker,  aged  twenty-fonr,  sustained,  in  May,  1885,  in  jumping 
and  slipping,  a  severe  strain  of  the  left  side  of  the  small  of  the  back,  which  was  fol- 
lowed by  sharp  pain  and  stiffness  for  a  few  days.  It  subsided  spontaneously,  but  left 
behind  a  soreness  of  varying  intensity.  May  SO,  1886. — Fever  set  in  with  intense  lum- 
bar pain,  but  swelling  came  on  very  slowly.  Though  looked  for,  it  could  not  be  made 
out  until  July  10th,  when  Dr.  E.  Schwedler  ascertaiued  its  presence.  The  kidneys, 
gut,  and  spinal  column  were  found  normal.  July  12th. — Incision  by  gradual  dissection 
was  ijracticed  under  ether.  The  abdominal  muscles  being  divided,  the  edge  of  the 
quadratus  lumborum  was  exposed.  Probatory  puncture  in  the  bottom  of  the  wound 
had  to  be  done  five  times  before  pus  was  found  high  up  close  to  the  edge  of  the  twelftli 
rib,  beneath  the  quadratus  muscle.  This  was  drawn  aside,  and  the  cavity  was  opened 
by  Ililton-Roser's  method.  About  an  ounce  and  a  half  of  odorless  pus  escaped,  and 
digital  exploration  showed  that  it  had  been  contained  in  a  small,  smooth-walled  cavity. 
Drainage  and  antiseptic  dressings  being  applied,  the  wound  was  irrigated  and  dressed 
daily;  later  on,  at  longer  intervals.     The  patient  was  discharged  cured  September  6th. 

i.  Anal  Abscess.  Fistula  in  Ano. — The  anus,  the  final  strait  through 
whicli  all  excrementitious  matter  must  pass,  is  subject  to  a  great  number  of 
traumatisms  from  within  and  without.  Foreign  bodies,  such  as  pits  and 
kernels,  chicken-  and  fish-bones,  are  frequently  caught  by,  and  imbedded  in 
the  mucous  lining  of  the  sphincter  muscle.  The  rough  introduction  of 
syringe-points  for  the  application  of  enemata,  scratching  and  manipulation 
of  itching  and  bleeding  i)iles,  the  surgeon's  digital  exploration,  sodomy, 
and  the  forcible  expulsion  of  massive  fgeces,  lead  to  superficial  injuries  of  the 
mucous  membrane  and  outer  skin  of  the  anal  region.  Persons  whose  hands 
and  faces  are  habitually  unclean  do  not  scrui)le  much  about  the  untidy  con- 
dition of  their  breech.     And  the  faeces  of  even  the  most  cleanly  swarm  with 


DIAGNOSIS  AND  TEEATMENT  OF  PHLEGMON.  255 

bacteria.    In  view  of  these  facts,  the  frequency  of  ulcerative  and  suppurative 
affections  of  the  anal  region  must  appear  very  natural. 

Anal  abscesses  are  generally  located  in  the  iscliio-rectal  fossa.  This  is 
the  space  limited  by  the  rectum  on  the  mesial  side,  the  tuberosity  of  the 
ischium  externally,  the  levator  ani  muscle  above,  the  superficial  perineal 
fascia  below.  It  is  very  rare  to  meet  with  a  periproctitic  abscess  situated 
above  the  levator  ani.  If  such  is  the  case,  we  have  to  deal  with  graver 
affections  involving  the  pelvic  organs,  or  with  abscess  from  ulceration  due 
to  stercoral  impaction  caused  by  cancerous  rectal  stricture. 

Case. — Mary  Steiger,  aged  fifty-nine.  Far-gone  cancer  of  rectum.  Stenosis  very 
tight,  causing  great  difficulty  at  defecation.  A  profuse  purulent  discharge  from  the 
anus  indicated  tlie  presence  of  ulcers  or  an  abscess  above  the  stricture.  Exploration 
of  the  rectum  above  the  cancer  was  absolutely  impossible.  High  temperatures  were 
noted.  Aiigiist  13, 1885. — Anterior  colotomy  in  the  German  Hospital.  No  diminution 
of  fever  after  the  operation.  August  16th. — Wound  healed  by  the  first  intention. 
August  17th. — Patient  delirious.  Discharge  from  anus  very  profuse.  August  18th. — 
Patient  died  with  symptoms  of  septicaemia.  Post  mortem  revealed  firm  union  of 
colotomy  wound  throughout  and  a  normal  peritoneal  cavity.  In  the  sacral  excavation, 
just  above  the  massive  ulcerated  cancer,  a  very  large  fetid  abscess  vs^as  found. 

The  presence  of  anal  abscess  is  the  source  of  intense  suffering  to  the 
patient,  and  ascertaining  of  its  precise  location  by  the  surgeon  is  generally 
not  very  difficult.  By  digital  examination  of  the  rectum  a  resistant,  hard, 
or  sometimes  fluctuating  swelling  can  be  felt  protruding  laterally  into  the 
gut.  Early  incision  is  very  urgently  indicated,  as  upon  it  may  depend  the 
avoidance  of  the  formation  of  fistula,  or  of  a  dissecting  or  "horse-shoe 
abscess,"  which  may  detach  almost  the  entire  lower  gut  from  the  adjacent 
connective  tissue.  This  latter  form  of  abscess  is  especially  to  be  feared,  as 
its  healing  is  extremely  difficult.  But,  where  fluctuation  is  absent,  success- 
ful evacuation  of  a  deep-seated  periproctitic  abscess  is  no  easy  matter. 

After  a  purge  and  enema,  the  patient  should  be  ansesthetized  and 
brought  into  Bozeman's  or  the  lithotomy  position.  (See  Fig.  122,  page  154.) 
A  sponge  tied  to  a  piece  of  stout  silk  is  pushed  well  into  the  rectum,  and 
the  lower  end  of  the  gut  and  the  anal  region  are  flushed  with  corrosive-sub- 
limate lotion.  Then  the  index-finger  is  introduced  and  placed  against  the 
swollen  side  for  fixation.  A  stout  exploring  needle  is  thrust  through  the 
skin  into  the  swelling  repeatedly  from  without  until  it  strikes  the  suppurat- 
ing focus.  It  is  left  in  situ  for  a  guide,  and  an  ample  incision  is  gradually 
extended  until  the  abscess  is  freely  opened.  The  wound  should  have  the 
shape  of  a  funnel,  its  apex  being  in  the  abscess.  This  will  secure  natural 
drainage.  The  wound  is  loosely  packed  with  iodoformed  gauze,  and  the 
anus  is  inclosed  in  a  moist  dressing,  which  should  be  renewed  every  day. 
Daily  irrigation,  or  in  very  irritable  patients  a  sitz  bath,  will  have  to  main- 
tain cleanliness. 

In  cases  where  extensive  detachment  of  the  rectum  or  perforation  into 
the  gut  has  taken  place,  simple  incision  will  be  insufficient,  and  division  of 
the  intervening  bridge  will  be  necessary. 


256  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

By  spontaneous  evacuation  outward,  external  incomplete  fistula  will  be 
established.  Some  of  these  cases  can  still  be  cured  by  a  free  bloody  dilata- 
tion of  their  orifice,  and  a  careful  antiseptic  treatment  as  above  indicated. 
But  most  of  them  are  complete  fistulm,  the  inner  openings  of  ivhich  can  not 
he  found  on  account  of  their  minuteness. 

Cases  of  incomplete  internal  and  of  complete  fistula  should  be  cut. 

In  incomplete  inner  fistula  a  Sims'  vaginal  speculum  is  used  for  exposing 
the  entrance  to  the  sinus.  A  bent  probe  and  alongside  of  this  a  bent 
grooved  director  is  introduced  into  it,  and  is  pushed  well  outward  toward 
the  skin,  which  is  incised  over  the  point  of  the  instrument.  After  this  the 
intervening  bridge  is  divided. 

Complete  anal  fistula,  especially  where  several  sinuses  exist,  should 
always  be  carefully  explored  before  the  incision  is  made,  as  otherwise 
pockets  and  branching  sinuses  may  be  overlooked.  A  silver  probe  should 
be  introduced  into  each  sinus  and  left  in  situ  until  its  turn  for  cutting 
should  come.  A  grooved  director  is  carried  into  the  gut  along  one  of  the 
probes,  is  caught  up  by  the  tip  of  the  left  index-finger,  and  turned  out  of 
the  anus.  The  bridge  of  tissue  taken  up  by  it  is  then  divided.  The  edges 
of  the  cut  are  well  drawn  apart  by  four-pronged  sharp  hooks,  in  order  to 
facilitate  securing  and  tying  of  spurting  vessels.  The  next  sinus  is  taken 
up  after  the  first,  and  every  nook  and  recess  is  carefully  examined  and  split 
open  until  natural  drainage  is  secured  everywhere.  Free  irrigation  of  tlie 
wound  should  be  employed  during  the  whole  process.  When  haemorrhage 
is  properly  attended  to,  all  the  old  granulations  should  be  forcibly  scraped 
away  with  the  sharp  sjioon,  and  the  wound  should  be  packed  with  narrow 
strips  of  iodoformed  gauze.  After  this  the  sponge  is  withdrawn  from  the 
rectum,  and  a  moist  dressing  is  applied  and  held  in  place  by  a  T-bandage. 
(Fig.  126,  page  157.) 

XoTE. — When  the  internal  orifice  can  not  be  found,  or  a  burrow  extends  upward  beyond 
it,  the  grooved  director  should  be  inserted  as  high  up  as  the  cavity  or  sinus  permits,  and  thence 
should  be  thrust  through  the  mucous  membrane  into  the  gut. 

The  length  of  time  required  for  the  cure  of  fistula  in  ano  will  depend 
on  the  extent  and  form  of  the  wound  made  by  the  surgeon.  In  simple 
cases  a  fortnight  or  three  weeks  will  suffice  ;  complicated  ones  may  need 
months.  In  favorable  cases,  that  is,  where  the  fistula  is  straight  and  single, 
cure  can  he  very  much  hastened  hy  excision  and  suture  of  the  entire  fistu- 
lous trade.  The  restitution  of  the  parts  to  their  normal  condition  will  at 
the  same  time  insure  against  incontinence.  The  callous  lining  of  the  sinus 
is  carefully  excised  with  forceps  and  curved  scissors,  and  the  remaining 
wound  is  united  by  several  tiers  of  buried  catgut  sutures,  the  ends  of  which 
should  be  clipped  off  short.  The  uppermost  tier  of  sutures  should  not 
inclose  the  mucous  membrane,  but  the  curved  needle  should  be  introduced 
close  to  its  edge  on  one  side,  and  brought  out  in  the  same  manner  on  the 
other  side.  Thus  inversion  of  the  mucous  lining  will  be  avoided,  and  the 
stitches,  being  buried  under  the  overlapping  edges  of  the  mucous  mem- 
brane, will  be  protected  from  infection  by  intestinal  contents.     The  exter- 


DIAGNOSIS  AND  TREATMENT  OF  PHLEGMON. 


25T 


nal,  that  is,  cutaneous,  part  of  the  wound  can  be  closed  by  silver-wire  stitches. 
Free  irrigation  of  the  wound  during  the  entire  time  of  the  ojaeration  is  indis- 
pensable to  preserve  asepsis. 
Iodoform  is  dusted  over  and 
rubbed  into  the  line  of  union, 
and  the  anus  is  inclosed  in  a 
moist  dressing. 

Case. — Simon  SchulLof,  labor- 
er, aged  forty -three  and  a  half,  re- 
ceived, during  the  Anstro-Prus- 
sian  war  of  1866,  a  bayonet  wound 
near  the  anus.  Suppuration  and 
the  formation  of  fistula  followed, 
and  resisted  three  operations  which 
had  been  performed  since  that 
time.  February  5,  1887. — Under 
ether,  the  fistula  was  slit  up  at 
the  German  Ho^^pital.  Its  exter- 
nal orifice  was  nearly  two  inches 
from  the  anal  margin ;  the  inter- 
nal one,  one  inch  and  a  half  up 
the  rectum.  The  direction  of  the 
track  was  straight,  and  no  lateral 
sinuses  were  present.  The  en- 
tire cicatricial  lining  of  the  fistula  was  excised  with  forceps  and  curved  scissors,  and 
the  internal  defect  was  united  with  three  tiers  of  fine  catgut  sutures.     The  external 

wound  was  brought  together  with  two  silver- 
wire  stitches.  Into  the  outer  angle  of  tbe 
skin- wound  a  short  piece  of  slender  rubber 
drainage-tube  was  placed.  A  pledget  of  iodo- 
formed  gauze  was  placed  into  the  anus,  and 
the  wound  was  dressed  with  gauze  and  a  T- 
bandage.  No  reaction  followed.  In  the  after- 
noon of  February  7th,  four  ounces  of  sweet- 
oil  were  injected  into  the  gut,  and  the  oil- 
soaked  gauze  was  withdrawn  from  the  anus. 
^^^MB   ■  An  hour  after  this  a  large  enema  of  soap- 

J^j^^^m^,  water  was  administered,  and  brought  away  a 

liquid  stool.  The  next  morning  a  saline  laxa- 
tive was  given,  and  was  continued  every  day, 
each  stool  being  followed  by  irrigation  of 
the  anus  to  free  it  from  excrementitious  mat- 
ter. Februanj  lOth.— The  silver  stitches  and 
rubber  tube  were  removed.  The  accompany- 
ing cut  shows  the  condition  of  the  wound  on 
the  tenth  day  after  the  operation.  The  action 
of  the  sphincter  was  perfect.     (Fig.  189.) 


Fig.  188. — Operation  of  fistula  in  ano.  Grooved  director 
passed  through  fistula  and  brought  out  of  the  anus, 
from  which  is  seen  depending  a  thread  holding  sponge 
pushed  well  up  the  rectum.  "(Simon  Schulhof's  case.) 


Fig.  189. — Eesult  after  excision  and  suture 
of  fistula  in  ano.     (Simon  Schulhof's  case.) 


Eegarding  the  management  of  the  first  and  subsequent  evacuation  of 
the  bowels,  the  reader  is  referred  to  the  chapter  on  hsemorrhoids  (page  156). 


258  RULES  OF  ASEPTIC   AND  ANTISEPTIC  SURGERY. 

In  very  extensive  cases  of  fistula  of  long  standing,  where  the  inner 
orifice  is  very  high  up,  say  two  inches  or  more  above  the  anal  opening, 
and  where  avoidance  of  hgemorrhage  is  rendered  imperative  on  account  of 
the  ansemic  condition  of  the  jjatieut,  the  elastic  ligature  can  he  successfully 
substituted  for  the  knife.  The  grooved  director  is  carried  through  the 
sinus  into  the  gut  as  usual,  and,  if  possible,  its  point  is  turned  out  of  the 
anus.  Where  this  is  impossible,  a  slender,  soft,  silver  probe  is  armed  with 
a  fillet  of  stout  silk,  to  the  end  of  which  a  piece  of  elastic  ligature  or  a 
small-sized  drainage-tube  (the  size  used  on  infants'  feeding-bottles  is  very 
good)  is  firmly  tied.  The  silver  probe  is  next  carried  along  the  grooved 
director  into  the  gut,  its  point  is  caught  up  by  the  tip  of  the  left  index- 
finger,  and  being  bent  upon  itself  is  grasped  with  a  stout  pair  of  dressing- 
forceps  and  withdrawn.  Thus  the  silk  thread  will  be  placed  into  the  sinus, 
and  with  a  seesaw  motion  will  clear  a  way  for  the  elastic  ligature,  which  is 
drawn  through  after  it.  The  ends  of  the  elastic  ligature,  being  firmly  held 
each  by  one  hand,  are  well  drawn  upon,  and  become  tense  and  attenuated. 
Thus  stretched,  they  are  crossed  over  each  other  in  front  of  the  anus,  and 
are  secured  in  this  position  by  a  ligature  of  silk.  As  soon  as  the  rubber  is 
released,  it  crowds  up  against  the  silk  ligature,  and  is  held  securely  in 
place.     Its  ends  are  trimmed  off  short. 

The  elastic  ligature  is  in  every  way  preferable  to  the  silken  one,  as  it 
cuts  through  more  rapidly,  and  does  not  require  re  tightening. 

Where  the  external  orifice  of  the  fistula  is  not  close  to  the  anal  opening, 
the  intervening  skin  must  be  cut  through  with  the  knife  before  the  tight- 
ening of  the  ligature,  to  avoid  the  intense  pain  due  to  strangulation  of  the 
cutaneous  nerves. 

Incontinence  is  occasionally  produced  by  fistula  operations  requiring 
single  or  multiple  division  of  the  entire  sphincter.  In  these  cases  a  sec- 
ondary proctoplasty  offers  fair  chances  of  partial  or  complete  recovery  of 
the  function  of  the  muscle. 

Case. — Barto  Weil,  brewer,  aged  fifty-six,  suffered  from  distressing  incontinence 
of  the  rectum,  caused  by  four  extensive  fistula  operations,  performed  successively  for 
the  horseshoe  variety  of  this  aftection.  At  the  last  operation  the  author  applied  two 
elastic  ligatures,  one  of  which  reached  three  inches,  the  other  three  inches  and  a  half 
up  the  rectum.  An  irregular  gaping  aperture  remained,  from  which  rectal  mucous 
membrane  protruded  in  a  number  of  folds.  One  granulating  oblong  surface  was  still 
extending  nearly  two  inches  into  the  gut.  May  28^  1886. — Under  ether,  the  entire 
irregular  cicatrix  was  excised,  and  the  remaining  flaps  of  mucous  membrane,  together 
with  the  lower  end  of  the  uncut  rectum,  were  dissected  up  and  drawn  well  dov/n. 
liy  a  large  number  of  catgut  stitches  the  cylindrical  shape  of  the  anal  opening  was 
re-established,  and  the  new  anal  ring  was  sewed  to  the  external  skin.  A  triangular 
defect  remaining  on  the  right  of  the  anus  was  covered  by  a  skin-flap  shaped  out  of  a 
shrunken  iotegumental  caruncle  found  posteriorly.  Two  small  drainage-tubes  were 
placed  well  up  between  rectum  and  ischio-rectal  connective  tissue.  Primary  union 
followed  through  the  greater  extent  of  the  wound,  and  ultimately  continence  was 
fairly  re-established.     The  patient  was  discharged  cured  July  24,  1886. 


EEYSIPELAS  AND   PSEUDO-ERYSIPELAS. 


259 


CHAPTER  VII. 


ERYSIPELAS  AND  PSEUDO-ERYSIPELAS. 


The  rules  of  aseptic  management  described  in  former  chapters  are  the 
best  safeguard  against  the  infection  of  operative  wounds  by  the  specific  coc- 
cus of  erysipelas.  (Fig.  131,  jiage  169  ;  Plate  II,  Figs.  5  and  6  ;  and  Fig. 
190.)  The  author  has  observed  only  four  cases  of  wound  erysipelas  in  ten 
years  both  of  public  and  private  practice.  In  one  of  these,  in  1879,  ery- 
sipelatous infection  was  transmitted  from  a  case  of  so-called  idiopathic 
erysipelas  of  the  face  to  the  genitals  of  a  woman  in  childbirth  by  the  author's 
hands,  in  spite  of  ordinary  measures  of  cleanliness.  Had  disinfection  been 
applied  after  the  usual 
washing  of  the  hands,  the 
patient  might  have  been 
living  to  this  day. 

The  other  case  of  ery- 
sipelas was  observed  after 
the  first  visit  of  a  nev/ 
member  of  the  house- 
staff  of  Mount  Sinai  Hos- 
pital, at  which  the  dress- 
ing of  a  nearly  healed 
wound  was  changed  by 
the  young  physician  in 
question.  The  case  was 
cured. 

XoTE. — The  time  of  changes 
in  the  house-staff  of  the  surgical 
wards  of  hospitals  is  generally 
signalized  by  unexpected  suppu- 
rations. The  author  has  learned 
to  dread  the  loss  of  a  good  and 
well-trained    assistant,   who    is 

occasionally  replaced  by  an  ineflHcient,  uncleanly,  and  indolent  personage.  Disaster  can  be 
averted  at  such  times  only  by  increased  vigilance  and  redoubled  diligence  on  the  part  of  the 
visiting  surgeon  in  personally  supervising  the  details  of  the  service. 

The  third  case  was  mentioned  in  the  paragrajih  on  perityphlitic  abscess. 

The  last  case  of  erysipelas  within  the  author's  experience  was  that  of  a 
young  woman  suffering  from  caseous  cervical  glands.  For  cosmetic  reasons 
the  glandular  swellings  were  punctured  with  a  narrow  bistoury,  and,  a  small 
curette  being  introduced  into  the  broken-down  center  of  the  gland,  its  case- 
ous contents  were  scraped  out.  The  small  wounds  were  drained  with  cat- 
gut.    ErysijDelas,  commencing  from  one  of  the  punctures,  set  in,  but  ended 


Fi 


1'JO. — Section  of  erysipelatDUs  skin  of  head  (70O 
diameters  i.     (Koeli.) 


260  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

iu  cure.     Undoubtedly  either  the  bistoury  or,  more  likely,  the  sharp  spoon 
was  the  carrier  of  the  virus. 

There  is  not  one  among  the  many  topical  remedies  recommended  by  the 
writers  for  erysipelas  that  is  pre-eminent  in  limiting  or  stopping  the  affec- 
tion. The  author's  local  treatment  consists  in  moist  antiseptic  dressings 
inclosing  the  affected  parts,  with  a  general  supporting  treatment  by  proper 
nourishment  and  stimulants.  The  much-praised  specific  effect  of  the  tinct- 
ure of  iron  is,  to  say  the  least,  very  problematic. 

Note. — Lately  Kraske  has  published  a  series  of  cases  in  which  multiple  scarification  and 
puncture  of  the  affected  parts,  especially  along  the  line  of  the  spread  of  the  disease,  has  led  to 
prompt  cure.  The  little  operation  is  followed  by  the  application  of  a  moist  antiseptic  dressing. 
As  the  principle  of  this  mode  of  therapy  is  rational,  consisting  in  depletion  and  disinfection,  it 
would  deserve  extended  trial. 

An  unmixed  infection  by  the  coccus  of  erysipelas  will  never  cause  ab- 
scesses. Whenever  abscesses  form  with  erysipelas,  we  have  to  deal  with  a 
mixed  infection,  namely,  by  the  coccus  of  erysipelas,  and  by  one  or  another 
of  the  pus-generating  cocci. 

Phlegmon  and  erysipelas  also  represent  a  mixed  form  of  infection,  but 
this  combination  is  rare.  What  is  generally  called  phlegmonous  erysipelas 
is  commonly  no  erysipelas  at  all.  It  is  a  phlegmon  produced  by  the  pyo- 
genic chain-coccus,  the  spread  of  which  along  the  lymphatics  resembles  that 
of  true  erysipelas. 

Pseudo-erysipelas  is  an  erysipelatoid  skin  affection  of  the  fingers  and 
hand  that  resembles  true  erysipelas  in  most  of  its  morphological  features. 
But  it  presents  this  important  clinical  difference,  that  it  never  is  accompa- 
nied by  fever.  The  affection  is  very  tractable,  as  the  application  of  a  three- 
per-cent  carbolic  lotion  for  a  few  hours  will  generally  consummate  a  cure. 
Its  cause  is  a  specific  coccus  described  by  Rosenbach. 


PART    III. 


TUBERCULOSIS  : 
ITS  ASEPTIC  ANT>  AI^TISEPTIO   TEEATMEISTT 


35 


CHAPTER   VIII. 


NATURAL   HISTORY  AND    TREATMENT  OF  TUBERCULOSIS. 


I.     ETIOLOGY    OF    TUBERCULOSIS. 


Koch's  discovery  of  the  specific  bacillus  of  tuberculosis  has  brought 
about  a  recoustruction  of  pathological  classification  and  nomenclature  that 
commends  itself  by  clearness  and  simplicity.  Miliary  tuberculosis  of  the 
lungs  and  other  internal  organs,  scrofulous  affections  of  the  lymphatic 
glands,  the  various  forms  of  surgical  tuberculosis,  as,  for  instance,  white 
swelling  and  caries,  finally  the  several  forms  of  lupus,  are  manifestations  of 
one  and  the  sflme  mor- 
bid process — namely,  of 
cellular  decay  caused  by 
the  deleterious  influence 
of  a  vegetable  parasite, 
Koch's  tubercle  bacillus. 

The  identity  of  this 
bacillus  can  be  indubi- 
tably established  by  cer- 
tain modes  of  staining. 
1^0  other  known  micro- 
organism will  be  affect- 
ed b}^  Koch's  or  Ehr- 
lich's  mode  of  staining 
like  the  tubercle  bacil- 
lus. It  appears  under 
the  microscope  as  a  blue, 
elongated  body  of  the 
length    of    half    a    red 

blood-corpuscle,  and  is  found  occupying  alone  or  in  company  with  other 
individuals  a  giant  cell  generally  located  in  the  center  of  a  fresh  tubercle. 
{Figs.  191,  192,  and  193.) 

The  distribution  of  the  tubercle  bacillus  is  very  unequal.  It  is  found  in 
large  numbers  where  the  invasion  of  the  disease  is  recent,  or  where  it  is 
rapidly  extending.  It  is  very  scanty  in  chronic  affections  like  glandular 
scrofulosis  or  lupus. 


'►^^-£^ 


Fig.  191. — Miliary  tubercles  of  lunsf,  with  central  caseation 
(50  diameters).     (Koch.) 


264 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


^^-  «    *t     *      ,;;?.. 

-X- 

%e 

1^ 

® 

f 

^-^^._ 

m^ 

-f  f>'"^~ 

•-S"i 

.  •»;-* 

~'^ 

-»-,     stf      ■ 

3?        ■ 

^-.-- 

"<' 

•'  m 

'-—          "^  '" ' 

-- 

_  A-             •.  - 

m 

^  .--- 

Fig.  192. — Part  of  one  tubercle  from  foiegoing 
illustration.  Bacilli  interspersed  between  nu- 
clei (700  diameters).     (Koch.) 


The  peculiarity^  of  the  tubercle  bacillus  is  to  incorporate  itself  with  a 
white  blood-corpnscle,  and  to  influence  it  in  such  a  manner  as  to  convert 
it  into  a  lymphoid  cell  of  somewhat  large  proportions.     This  cell  becomes 

sessile  in  some  part  of  the  body. 
Alter  a  while  new  lymphoid  cells 
appear  in  the  vicinity  of  the  first 
cell,  which  by  this  time  will  have 
grown  to  the  proportions  of  a  mul- 
tinnclear  giant  cell,  containing  a 
number  of  bacilli  (Fig.  195).  As 
the  infection  spreads  along  the  pe- 
riphery, peculiar  changes  are  seen 
to  occur  in  the  center  of  the  nodule 
composed  of  lymphoid  cells.  The 
nuclei  of  the  lymphoid  and  giant 
cells  lose  their  staining  capacity  and 
coagulate  into  a  granular  mass.  The 
bacilli  contained  within  them  dis- 
aj^pear,  leaving  behind,  however,  a 
crop  of  invisible  spores  that,  trans- 
ferred to  a  suitable  soil,  will  readily 
produce  a  new  growth  of  bacilli. 
With  the  formation  of  this  co- 
agulated mass  of  decayed  cell-elements  the  process  of  caseation  is  estab- 
lished. The  presence  of  this  mass  of  necrosed  tissue  acts  as  an  irritant 
upon  the  capillaries  of  the  vicinity,  and  a  wall  of  new-formed  granulation 
tissue  is  thrown  up  around  the  focus.  Should  the  infection  of  the  neighbor- 
ing tissues  occur  before  the  protecting  wall  of  new-formed  granulation  tissue 
is  completed,  exten- 
sive caseous  infil- 
tration will  be  the 
result. 

The  barrier  of 
new-formed  granu- 
lations is  also  liable, 
here  and  there,  to 
invasion  by  bacilli, 
and  therefore  casea- 
tion will  generally 
extend  in  a  rather 
irregular  manner. 

An  increased  ex- 
udation of  blood- 
serum    and    white 

blood-corpuscles  will  finally  bring  about  emulsification  of  the  cheesy  focus, 
which  then  represents  the  beginning  of  a  cold  abscess. 


Fl...    llKj. 


-I'art  of  miliary  tubercle  from  a  case  of  basilar  menin- 
gitis (Till/ diameters).     (Koch.) 


ETIOLOGY  OF  TUBEECULOSIS. 


2f;5 


Fig.  194. — Giant  cell  containing  bacilli  taken  from 
miliary  tubercle  (700  diameters).     (Koch.) 


There  is  no  organ  of  the  human  body  that  is  exempt  from  the  possibility 
of  tuberculosis. 

The  predisposition  to  infection  by  the  ubiquitous  spores  of  the  bacillus 
of  tuberculosis  is  manifestly  increased  by  any  kind  of  deterioration  of  local 
or  general  bodily  vigor.  Mal- 
nutrition, whether  due  to  an  at- 
tack of  measles  or  the  whooping- 
cough,  or  to  a  chronic  catarrh 
of  the  infantile  gut  caused  b}" 
improper  nursing,  or  to  long- 
continued  suj^puration  from  an 
osteom3^elitic  sequestrum,  is,  as 
a  matter  of  actual  observation, 
very  often  followed  by  local  and 
general  tuberculosis. 

The  most  common  way  of  m- 
fection  is  undoubtedly  that  by 
the  lungs.  Catarrhal  affections 
of  the  bronchial  mucous  mem- 
brane, regularly  accompanied  by  superficial  denudations  of  the  epithelium, 
serve  as  portals  for  the  entrance  and  implantation  of  the  spores  of  the  bacil- 
lus. And,  as  the  deterioration  of  the  general  state  of  health  after  measles  is 
combined  with  a  catarrhal  condition  of  the  bronchi,  infantile  tuberculosis  is 

most  commonly  acquired  after  this 
eruptive  disease.  For  unknown 
reasons  the  pulmonary  tissues  of 
children  do  rarely  become  involved 
in  serious  tubercular  trouble  ;  but 
the  virus  is  promptly  transmitted 
to  the  bronchial  lymphatic  glands 
(Fig.  195),  which  undergo  casea- 
tion, and,  on  account  of  their  close 
vicinity  to  the  thoracic  duct  and. 
various  vessels,  serve  as  a  depot  for 
further  distribution. 

We  owe  to  Ponfick  proof  of  the 
fact  that  perforation  of  a  caseous 
focus  into  the  thoracic  duct  may 
cause  a  more  or  less  general  dissemination  of  tuberculosis.  Koch  himself 
has  demonstrated  another  manner  of  distribution  in  the  involvement  and 
caseation  of  arterial  walls.  But  the  most  common  way  of  systemic  tubercu- 
lar infection  was  found  by  Weigert  in  the  decay  of  the  walls  and  perforation 
into  the  lumen  of  veins,  which  generally  hold  very  intimate  anatomical  rela- 
tions to  caseous  glandular  tumors. 

Entrance  of  small  quantities  of  tubercular  virus  into  the  general  circu- 
lation by  the  ways  above  indicated  will  lead  to  local  tubercular  affections  of 


Fici.  195.— Giant  cell,  "n-itli  radial  arrangement 
of  bacilli,  from  a  caseous  bronchial"  gland 
(700  diameters).     (Koch.) 


266 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


various  organs,  as,  for  instance,  the  bones,  testicle,  or  joints.     Massive  in- 
vasion, on  the  other  hand,  will  cause  fatal  general  miliary  tuberculosis. 

Tulercular  matter  carried,  along  ly  the  circulating  Mood  is  most  apt  to 
be  arrested  and  to  hecome  sessile  in  the  vicinity  of  the  terininal  arteries. 
The  views  expressed  in  the  chapter  on  the  localization  of  acute  infectious 
osteomyelitis  seem  to  be  applicable  also  to  the  localization  of  the  tubercular 
process.     (Page  195.) 

Another  rarer  manner  of  tubercular  infection  is  that  by  lesions  of  the 
skin.  A  Jewish  circumciser  suffering  from  pulmonary  and  faucial  tuber- 
culosis, communi- 
cated the  disease 
to  twelve  infants 
by  sucking  their 
preputial  wounds. 
This  used  to  be 
the  accepted  man- 
ner of  stanching 
haemorrhage  after 
ritual  circumcision 
in  former  times. 

Note.— In  1879  the 
author  was  the  victim  of 
local  tuberculosis  of  the 
pulp  of  the  thumb,  con- 
tracted by  the  infection 
of  a  small  cut  received 
during  the  amputation  of 
a  thigh  for  tuberculosis 
of   the  knee-joint,  com- 
plicated with  large  tubercular  abscesses  of  the  thigh  and  of  the  medulla  of  the  femur.     A  case- 
ating  elevated  ulcer  of  the  thumb  developed  and  persisted  for  six  weeks.     The  complaint  healed 
after  the  final  detachment  and  expulsion  of  two  caseous  plugs. 

The  dissemination  of  tubercular  matter  during  surgical  operations,  done 
for  the  cure  of  the  complaint,  was  first  pointed  out  by  Koenig, 

It  is  well  known  that  death  by  general  tuberculosis  is  seen  to  follow 
exsection  of  the  hip-joint  with  especial  frequency.  Upon  this  circum- 
stance is  based  the  statistically  proved  fact  that  the  expectant  or  rather 
non-operative  treatment  of  this  complaint  yields  better  results  than  an 
active  operative  therapy. 

Note. — These  facts  find  a  ready  explanation  in  the  circumstances  under  which  most  early 
exsections  of  the  hip-joint  are  carried  out.  The  depth  of  the  diseased  joint ;  the  diflSculty  of 
liberating  the  head  of  the  femur,  still  held  down  firmly  by  undestroyed  ligaments ;  the  desire  of 
operating  subperiosteally,  that  is,  with  the  employment  of  a  good  deal  of  blunt  force ;  the  forci- 
ble manipulations  in  distending  the  edges  of  the  deep  wound  by  retractors — all  serve  to  propel 
any  freed  caseous  matter  into  the  cut  orifices  of  veins  and  lymphatics.  The  result  is  that,  by 
the  time  the  local  tuberculosis  combated  by  the  surgeon  is  healed,  the  patient  succumbs  to 
meningeal  or  pulmonary  tuberculosis,  probably  chargeable  to  operative  interference. 


Fig.  196. — Giant  cell  containing  one  bacillus  from  Y'lg.  191 
(700  diameters).     (Koch.) 


TREATMENT  OF  TUBERCULOSIS.  267 


II.     COMPLICATION    OF    TUBERCULOSIS    WITH    PYOGENIC    OR 
SUPPURATIVE    INFECTION. 

Tubercular  decay  of  tissues  by  caseation  is  a  generally  slow  process,  as 
long  as  the  aifection  remains  subcutaneous — that  is,  occluded  from  access 
of  air  with  its  pyogenic  organisms.  But  let  a  tubercular  focus  of  the  lung 
perforate  into  a  bronchus,  or  let  a  group  of  caseous  glands,  or  a  cold  abscess 
communicating  with  a  distant  focus  of  the  spine  or  some  joint,  be  opened 
without  aseptic  precautions,  and  the  affection  will  have  at  once  entered 
upon  a  new  and  more  destructive  phase.  The  formerly  thin,  flocculent  dis- 
charge will  assume  a  more  purulent  character,  the  production  of  pus  will 
become  prodigious,  more  or  less  fever  will  set  in,  and  the  symptoms  of  a 
rapidly  progressive  local  destruction  of  tissue  accompanied  by  hectic,  will 
become  more  and  more  pronounced. 

A  new  infection  was  thus  implanted  upon  a  soil  already  impoverished  by 
ill-nutrition  and  preyed  upon  by  a  destructive  parasite.  To  the  slow  decay 
of  tuberculosis,  the  rapidly  disorganizing  forces  of  purulent  infection  were 
added.  The  seriousness  of  this  contingency  was  justly  comprehended  by 
old-time  surgeons,  who  abhorred  meddling  with  a  cold  abscess  or  any  covert 
strumous  affection.  Incision  of  a  cold  abscess  then  meant  purulent  infection 
of  the  cavity,  extending  to  the  often  inaccessible  primary  focus  of  the  dis- 
ease, hectic  fever,  and  rapid  emaciation  and  decay  of  the  patient. 

Just  appreciation  of  these  remarks  will  at  once  impress  upon  the  mind 
the  great  necessity  of  aseptic  measures  in  our  operative  dealings  with 
tubercular  affections. 


in.     TREATMENT     OF     TUBERCULOSIS. 

General  Principles. 

Considering  the  fact  that  about  seventy  per  cent  of  all  deaths  are  directly 
or  indirectly  caused  by  tuberculosis  of  various  organs,  principally  consump- 
tion, and  that  the  management  of  the  infectious  sputa  of  consumj)tives  is 
careless  in  the  extreme,  it  must  be  admitted  that  efforts  at  prevention  offer 
no  great  hope  of  success.  The  sputa  containing  active  bacilli  or  their  spores 
are  ejected  on  the  ground  or  floor,  dry  there,  and  are  converted  into  dust, 
which  will  penetrate  everywhere  and  will  cover  everything  with  its  deadly 
burden.  The  tent  of  the  Indian  and  the  palace  of  the  millionaire  are  pene- 
trated alike  by  dust  containing  dried  and  pulverized  sputa  of  consumptives, 
and  millions  of  spores  of  pyogenic  cocci,  derived  from  suppurating  wounds, 
the  discharges  of  which  are  carelessly  thrown  every  day  upon  the  ground, 
to  be  whirled  up  from  there  by  draughts  of  air. 

A  more  promising  line  of  prevention  can  be  cultivated  in  the  proper 
nourishment  and  regime  of  the  individual.  The  better  the  general  con- 
dition of  health,  the  fuller  and  more  abundant  the  blood  supply  of  this  or 
that  organ,  the  less  the  chance  of  its  becoming  the  seat  of  tuberculosis.     Or, 


268 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURaERY. 


if  passing  conditions  of  anaemia  caused  by  illness  or  loss  of  blood  have  led 
to  the  establishment  of  a  tubercular  focus,  raising  of  the  general  health  by 
proper  diet  and  exercise  in  the  pure  air  of  the  sea  or  of  high  mountains,  will 
check  and  often  wholly  eliminate  the  ravages  of  the  disease.  A  generous 
diet,  with  plenty  of  exercise  in  the  open  air,  is  the  l)est  preventive  and  sys- 
temic curative  of  tuberculosis.  To  the  observance  of  scrupulous  cleanliness 
in  the  household  and  in  our  per  social  habits  must  also  be  acceded  a  great 
protective,  and  in  sotne  measure  a  curative  influence. 

Local  Treatment  of  Tuberculosis. 

Knowledge  of  the  true  nature  of  the  various  forms  of  surgical  tubercu- 
losis has  led  to  a  clear  understanding  of  the  principles  governing  its  suc- 
cessful treatment.  Since  we  do  not  possess  any  therapeutic  agent  capable 
of  destroying  the  bacillus  of  tuberculosis  in  situ,  without  interfering  with 
the  tissues  that  harbor  it,  chemical  and  mechanical  influences  must  be 
brought  to  bear  upon  the  tuberculous  focus,  with  the  object  of  destroying 
and  removing  all  cell  elements  infested  with  the  specific  virus.  In  short, 
the  modern  treatment  of  local  tuberculosis  is  identical  with  that  accejjted 
for  the  cure  of  malignant  new  growths  ;  it  consists  in  a  more  or  less  com- 
plete reinoval  of  the  affected  tissues  or  organs  by  caustics,  the  hnife,  or  the 
gouge,  under  aseptic  precautions. 

1.  Cutaneous  Tuberculosis.  Lupus  (Fig.  197). — Various  chemical  caus- 
tics, the  actual  cautery,  and  excision  are  known  to  effect  a  cure  of  cuta- 
neous tuberculosis.  In- 
ternal medication  has  no 
effect  upon  it.  The  most 
destructive  forms  of  lupus 
are  those  representing  a 
complication  of  tubercu- 
losis with  pyogenic  infec- 
tion— as,  for  instance,  lu- 
pus exedens.  The  miliary 
nodes  nearest  the  surface 
caseate,  break  down,  and 
perforate,  and  the  way 
is  open  for  the  entrance 
of  pus-generating  cocci. 
Lupus  of  the  face  should 
be  treated  by  caustics 
and  scooping.  The  more 
radical  treatment  by  ex- 
cision is  not  to  be  commended  in  facial  lupus  on  account  of  the  disfigure- 
ment it  is  apt  to  cause.  Eelapses  are  frequent,  and  should  be  attacked  over 
and  over  again  as  soon  as  they  appear.  Lupus  of  non-exposed  jiarts  of  the 
skin  should  be  cxsected.  The  following  case  demonstrates  the  identity  of 
lupus  and  tuberculosis  : 


/r 


^ 


.^. 


m- 


jSk. 


_fe "'.rJ.^     fe' 


ii( 


11j7. — Section  of  lupous  i<kiii.     Giant  cell  contaiiunj. 
one  bacillus  (700  diameters).     (Koch.) 


TREATMENT  OF  TUBERCULOSIS.  269 

Case. — Otto  Krim,  aged  five.  Lupus  exedens  over  the  left  external  malleolus  of  the 
size  of  a  silver  dollar.  The  affection  existed  for  nearly  three  years ;  about  a  year  ago 
glandular  swelling  appeared  in  Scarpa's  triangle  of  the  left  side  and  in  the  correspond- 
ing groin.  Extensive  scrofulous  ulceration  of  the  skin  followed,  and  caseous  glands 
lay  exposed  in  the  bottom  of  the  inguinal  wound.  February  4,  1881. — Extirpation  of 
the  lupous  patch  and  of  the  glandular  masses  from  Scarpa's  triangle  and  above  Pou- 
part's  ligament.  The  peritonteum  was  exposed,  and  had  to  be  stripped  up  to  the  ex- 
ternal iliac  vessels  to  permit  complete  removal  of  the  glands.  Primary  union  of  tlie 
wounds  about  Poupart's  ligament.  The  malleolar  wound  healed  under  a  Schede  dress- 
ing.    February  27tTi. — Patient  discharged  cured. 

2.  Tuberculosis  of  the  Mucous  Membranes.  —  Scrofulous  rhinitis,  or 
coryza,  is  a  very  rebellious  affection  of  the  nasal  mucous  membrane.  It  is 
easily  recognized  by  the  chronic  swelling  of  the  mucous  covering  of  the 
nasal  cavity,  the  swollen  upper  lip,  open  mouth,  hard  hearing,  and  noisy 
breathing.  Its  surgical  importance  lies  in  its  tendency  to  produce  an  early 
affection  of  the  cervical  lymphatic  glands — scrofula.  Ulcei'ative  destruc- 
tion of  the  mucous  covering  of  the  nasal  bones  opens  the  way  for  the  ingress 
of  pyogenic  organisms,  which  bring  about  frequently  more  or  less  extensive 
necrosis.  An  intensely  fetid  odor  makes  the  breath  of  these  patients  in- 
tolerable. Termination  of  this  condition  is  best  accomplished  by  removal 
of  the  necrosed  bones  in  Eose's  dependent  position  of  the  head.  (Fig.  170, 
page  313.)  The  sequestra  are  easily  dislodged  by  the  sharp  spoon.  The 
haemorrhage  is  at  first  rather  profuse,  but  soon  subsides  on  irrigation  with 
ice-water.  Daily  irrigation  of  the  nasal  cavity  with  a  mild  solution  of  cor- 
rosive sublimate  (1  :  5,000)  should  be  used  until  discharges  cease  to  appear. 

Tuberculosis  of  the  anal  mucous  memhraoie  is  a  most  frequent  cause  of 
t\xhQrcv\ovi?>  fistula  in  ana.  Simple  slitting  up  of  these  fistulous  tracks,  lined 
with  caseous  granulations,  and  often  dotted  with  miliary  tubercle,  will  not 
accomplish  their  cure.  Every  nook  and  recess  of  the  fistula  must  be  carefully 
ex]Dlored,  and  all  caseous  or  granular  matter  must  be  removed  by  vigorous 
scooping  and,  if  need  be,  excision.  A  thorough-going  operation  will  always 
be  followed  by  improvement,  and  in  not  too  extensive  cases  by  local  cure. 

Tuberculosis  of  the  urethra  and  bladder  is  a  most  distressing  complaint, 
and  is  hardly  amenable  to  any  form  of  treatment.  Sedatives  and,  in  cases 
where  the  affection  of  the  neck  of  the  bladder  renders  life  intolerable  on 
account  of  the  unceasing  painful  strangury,  median  perineal  cystotomy,  fol- 
lowed by  drainage,  are  indicated. 

A  common  sequel  of  urethral  tuberculosis  is  caseous  epididymitis  and 
orchitis.  Testicular  tuberculosis  caused  by  urethral  disease  is  generally 
bilateral.  Single  tuberculosis  of  the  testicle,  on  the  other  hand,  is  gener- 
ally of  embolic  origin.     Its  sovereign  remedy  is  castration. 

3.  Tuberculosis  of  Lymphatic  Glands,  or  Scrofula  (Fig.  198). — Caseous 
chronic  lymphadenitis  is  one  of  the  most  common  affections  of  childhood  and 
adolescence.  Its  foundations  are  generally  laid  by  chronic  affections  of  the  oral, 
nasal,  and  aural  mucous  membranes,  by  tubercular  affections  of  the  cervical 
Tertebrse,  and  by  lupus  and  eczema  of  the  face  and  scalp.    The  incipient  stages 

36 


270 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


of  the  trouble  can  sometimes  be  controlled  by  timely  attention  to  the  causal 
disorders,  an  appropriate  general  treatment,  and  the  local  application  of 
one  or  another  pre^Daration  containing  iodine  in  the  shape  of  an  ointment. 

As  soon  as  caseation  has  been  well  established,  general  and  topical  treat- 
ment of  the  milder  sort  will  be  of  no  avail. 

The  modern  therapy  of  scrofulous  lymphatic  glands  is  dominated  by 
the  idea  that  they  are  not  only  the  cause  of  present  discomfort  and  suf- 
fering to  the  patient,  but  especially  that  within  them  is  contained  the  seed 
for  renewed  infection,  which  by  its  dissemination  through  the  circulation 
may  cause  other  local  affections  or  a  fatal  general  malady.  The  close  ana- 
tomical relation  of  most  lymphatic  glands  to  important  venous  trunks  or 
their  immediate  affluents  renders  their  early  attachment  by  inflammatory 
deposit  very  easy.      Cheesy  degeneration   will   ultimately  reach  the  wall 

of  the  vein  itself,  and  dissemina- 
tion of  the  tubercular  virus  through 
the  circulation  is  the  result. 

The  surgical  therapy  of  cheesy 
lymphadenitis  will  have  to  be  varied 
according  to  the  stage  of  the  dis- 
ease, the  chief  object  being  always 
thorough  removal  or  destruction  of 
all  infected  tissues. 

Where  there  is  central  caseation 
only,  and  no  fistula,  nor  an  appre- 
ciable abscess,  hodily  excision  of 
the  glandular  masses  is  most  appro- 
priate. The  neck  being  the  most 
common  seat  of  the  trouble,  a  few 
words  may  be  said  regarding  the 
detail  of  the  operative  treatment  of 
scrofulous  cervical  glands. 

The  incision  should  be  ample, 
and,  if  the  tumors  be  very  exten- 
sive, the  formation  of  a  flap  is  advisable.  The  capsule  of  the  uppermost 
gland  being  split,  the  glandular  body  is  shelled  out  of  its  nest.  This  is 
much  facilitated  by  an  assistant's  holding  aside  the  detached  capsule  with 
a  small,  sharp  retractor  while  the  surgeon  suitably  changes  the  position  of 
the  mass  by  turning  it  one  way,  then  another,  until  all  the  looser  attach- 
ments are  divided.  Great  care  must  be  exercised  herein  not  to  lacerate  or 
crush  the  brittle  substance  of  the  gland. 

Each  gland  has  its  afferent  and  efferent  vessels,  and  these  form  a  sort  of 
pedicle,  which  must  be  tied  off  before  it  is  cut. 

In  cases  of  very  extensive  involvement  of  the  cervical  glands  situated 
both  in  the  vascular  and  intermuscular  interspaces  (see  page  208),  it  is  very 
advisable  to  cut  the  sterno-mastoid  muscle  across  and  in  two.  The  spinal 
accessory  nerve  will  be  found  near  its  posterior  margin,  and  should  be  saved. 


Fig.  198. — Giaut  cell  coritaiuiuii'  one  bacillus 
from  a  scrofulous  gland  of  the  neck  (700 
diametersj.     (Koch.) 


TREATMENT  OF  TUBERCULOSIS.  271 

The  stumps  of  the  divided  sterno-mastoid  muscle  are  raised  from  their 
mesial  attacliments,  and  one  is  turned  up,  the  other  is  turned  down.  The 
otherwise  difficult  and  even  dangerous  dissection  of  the  glands  from  the 
vicinity  of  the  large  vessels  is  made  much  easier  by  the  free  exposure  afforded 
by  cutting  the  sterno-mastoid,  which  should  be  reunited  by  a  number  of 
catgut  stitches  after  the  completion  of  the  exsection. 

The  manner  of  placing  the  drainage-tubes,  the  suture,  and  dressings, 
do  not  differ  from  the  usual  arrangement.  Before  closing  the  wound,  a 
thorough  mojiping  out  with  a  strong  solution  (1  :  500)  of  corrosive  subli- 
mate is  necessary,  to  make  sure  of  destroying  all  spores  of  tubercle  bacilli 
that  may  have  escaped  with  cheesy  matter  from  accidentally  injured  glands. 

When  dealing  with  progressed  central  cheesy  abscesses  of  the  cervical 
glands,  a  different  course  must  be  pursued.  Incision  of  each  abscess,  fol- 
lowed by  a  thorough  scooping  away  of  all  granulations  and  broken-down 
glandular  tissue,  is  the  proper  treatment.  The  sharf  spoon  can  and  should 
be  used  rather  vigorously,  and  no  fear  need  be  felt  of  injuring  large  vessels 
lying  close  by  the  walls  of  the  abscesses,  as  there  is  a  tough  and  thick  wall  of 
organized  connective  tissue  interposed  to  protect  them.  A  drainage-tube  is 
to  be  inserted  into  each  cavity. 

Caseous  abscesses  that  have  perforated  spontaneously ,  or  have  been 
opened  inadequately,  generally  lead  to  tubercular  infection  of  the  subcuta- 
neous tissue  in  the  vicinity  of  the  aperture.  More  or  less  extensive  under- 
mining and  bluish  discoloration  of  the  sTcin  are  the  consequence.  The  un- 
dermined, irregular  edges  show  very  little  tendency  to  heal ;  they  become 
inverted,  and  if  healed,  present  an  ill-shapen,  uneven  scar. 

To  aid  and  hasten  the  inadequate  efforts  of  Nature,  it  is  necessary  to 
extirpate  or  gonge  out  the  glandular  bodies,  to  trim  away  all  the  under- 
mined portions  of  skin  with  the  curved  scissors,  payi7ig  no  regard  to  the  ex- 
tent of  the  resulting  ivound.  However  large  the  denudation,  it  will  heal 
rapidly  and  kindly  under  Schede's  dressing,  and,  on  account  of  the  mo- 
bility and  abundance  of  the  cervical  integument,  the  resulting  cicatrix  will 
be  nearly  linear  in  shape. 

Note. — Glandular,  cheesy  abscesses  on  the  necks  of  grown  girls  can  be  healed,  without 
leaving  a  conspicuous  scar,  by  repeated  punctures  with  a  stout  aspirating-needle.  The  contents 
of  the  abscess  being  removed  by  aspiration,  corrosive-sublimate  lotion  is  injected  through  the 
cannula,  and  is  again  withdra\\"n.  This  is  repeated  until  the  lotion  returns  clear  and  limpid, 
when  the  cannula  is  taken  out.  The  puncture-hole  is  protected  by  a  drop  of  iodoformed  collo- 
dion. The  process  is  repeated  whenever  the  abscess  refills,  until  the  cavity  becomes  closed. 
The  author  has  cured  two  cases  in  this  manner. 

4.  Tuberculosis  of  Tendinous  Sheaths. — Weeping  sinew  or  acute  syno- 
vitis of  the  tendinous  sheaths  sometimes  degenerates  into  a  chronic  affection 
of  their  synovial  lining  known  under  the  name  of  proliferating  hygroma. 
This  rebellious  affection  is  characterized  by  an  elongated,  fluctuating, 
irregular  swelling  of  the  carpal  region.  It  is  painless,  but  impedes  the  free 
use  of  the  fingers.  The  swelling  is  due  to  a  gelatinous  thickening  of  the 
sheaths  of  the  sinews.     The  tendons  finally  become  adherent  to  the  degen- 


970, 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


erated  mass,  thus  losing  their  free  mobility.  The  sacs  frequently  contain 
some  more  or  less  discolored  synovia;  and  sometimes  a  large  number  of  rice- 
kernel-shaped  concretions  of  fibrin. 


Fig.  199. — Group  illustrating  an  exsection  of  tubercular  tendinous  sheaths  of  the  palm. 

Topical  applications  make  no  impression  upon  this  disorder,  which  can 
be  cured  only  by  free  incision  and  methodical  removal  of  the  fibrinous 
bodies  and  the  gelatinous  sheaths  by  careful  dissection  in  artificial  anaemia. 
If  the  new  growth  extend  underneath  the  transverse  carpal  ligament,  and 
can   not  be  got  at  otherwise,  the   ligament  must  be  divided  to  permit 

thorough  removal.  The  carpal  ligament, 
fascia,  and  skin  are  united  by  several  tiers  of 
catgut  sutures,  a  slit  is  left  open  at  each,  end 
of  the  incision,  and  a  compressive  Schede's 
dressing  is  applied  to  the  arm  and  hand, 
which  should  be  placed  on  a  volar  splint  ex- 
tending to  the  line  of  the  metacarpo-phalan- 
geal  joints.  The  patient  is  directed  to  active- 
ly move  Ids  fingers  from  the  second  day  on, 
and  thus  to  fashion  grooves  in  the  blood-clot 
filling  the  interior  of  the  wound,  which  are 
to  become  new  tendinous  sheaths  after  the 
substitution  of  the  clot  by  new-formed  con- 
nective tissue.     (Figs.  199  and  200.) 

Case   I. — Samuel    H.,    medical    student,    aged 

twenty-five.     Tubercular  gelatinous  synovitis  of  all 

extensors  of  right  liand  and  of  flexors  of  left  hand. 

DecemherSO^  1886. — Extirpation  of  diseased  sheaths 

Yu..  iioM.- 1,11,,  ~  .,1  iticisioii  (in  pal-      of  extensor  tendons  of  riglit  hand  under  Esmarch  at 

mar  and  <iorsal  asviects  of  tlic  hand       ,,         .  ci.      .  ,-,        .,    ,      ,-  ■,^,47.       -n-     i.    1 

for  tendineal  tubireulosis.     (Case      Mount  Sinai  Hospital.   January  12th.— Fmi  ch&ngQ 

of  Samuel  11.)  of  dressings ;  primary  union.    By  January  20,  1887, 


^  f« 

■ 

»'' 

'11 

1  "^  ^^H 

"W'/' 

\'\ 

! ' 

L 

'"^J  it.  / 

TREATMENT  OF  TUBERCULOSIS.  273 

normal  function  re-established.  January  27th. — Similar  treatment  of  flexor  sheaths 
of  left  hand.  Double  ligature  and  division  of  superficial  palmar  arch  ;  division  of  car- 
pal hgament.  Suture  of  carpal  ligament,  fascia,  and  skin.  February  13th. — First 
change  of  dressings ;  primary  union.     March  15th. — Function  of  flexors  normal. 

Case  II. — Mina  Scheller,  aged  twenty-five.  Tuberculous  synovitis  of  extensor  ten- 
dons of  both  hands.  March  26^  1886. — Operation  of  right  hand  at  Mount  Sinai  Hos- 
pital. Primary  union.  April  6th. — Operation  of  left  baud  ;  primary  union.  Janu- 
ary^ 1887. — Function  of  both  hands  perfect. 

5.  Tuberculosis  of  Bone.  Caries.  Cold  Abscess.— Bone  tuberculosis  may 
appear  in  two  ways  :  On  one  haucl,  it  is  either  an  independent  affection  of 
the  shaft  of  a  long  bone,  preferably  in  the  vicinity  of  an  epiphyseal  line,  or 
it  is  a  deposit  in  the  epiphysis  itself,  which  by  extension  and  perforation  into 
the  joint  may  cause  tubercular  arthritis  ;  on  the  other  hand,  tubercular  in- 
volvement of  the  bone  may  be  caused  in  tubercular  arthritis  of  the  synovial 
type  by  ulceration  of  the  cartilage  and  direct  infection  of  the  exposed  bone. 
No  bone  is  wholly  exempt  from  tuberculosis.  The  skull,  the  spine,  the 
sternum,  ribs  and  scapula,  the  pelvis,  and  the  bones  of  the  extremities-  are 
all  liable  to  infection. 

The  characteristic  features  of  idiopathic  bone  tuberculosis  are  thicken- 
ing, the  cheesy  deposit,  and,  later  on,  ulcerative  processes,  against  which 
the  exuberant  production  of  feeble  and  deciduous  granulations  conducts  an 
uneven  and  unsuccessful  struggle.  In  their  turn  the  granulations  also  be- 
come infected  and  succumb  to  cheesy  degeneration,  and  thus  the  process 
goes  on  interminably.  Sequestra  of  large  size,  as  in  acute  osteomyelitis, 
are  never  produced  ;  but  the  granulations  contain  smaller  or  larger  rudi- 
ments of  dead  bone,  and  a  good  deal  of  bony  grit  is  to  be  felt  in  the 
secretions. 

Cold  abscesses  represent  the  accumulated  result  of  cheesy  degeneration 
and  emulsification.  They  travel  by  well-known  routes,  and  the  surgeon  is 
generally  able  to  conclude  from  the  place  of  their  external  appearance  where 
their  source  is  to  be  looked  for. 

Cold  abscesses  contain  an  enormous  mass  of  infectious  matter.  They 
are  a  drain  upon  the  patient's  health,  and  should  be  therefore  always  evacu- 
ated. Evacuation  can  be  clone  in  several  ways,  but  it  must  under  all  circum- 
stances be  done  ivith  strict  aseptic  precautions.  The  observance  of  asepticism 
is  of  especial  importance  where  the  focus  of  the  disease  is  inaccessible,  as 
for  instance  in  Pott's  disease. 

Note. — Evacuation  by  puncture  with  a  well-disinfected  trocar,  with  subsequent  injection  of 
a  solution  of  five  parts  of  iodoform  in  one  hundred  parts  of  ether,  was  proposed  by  Verneuil, 
and  has  been  found  very  effective  by  various  surgeons,  including  the  author.  The  injected  ether 
evaporates  in  and  distends  the  abscess  cavity.  Thus  the  iodoform  enters  every  nook  and  corner 
of  the  irregular  hollow,  where  it  exerts  the  undeniably  favorable  influence  of  all  iodides  upon 
the  tuberculous  process.  Undoubtedly,  abscess  cavities  thus  treated  fill  up  much  slower  than 
after  simple  evacuation.  Where  the  osteal  process  has  reached  its  termination,  they  do  not  re- 
fill at  all.  From  one  to  two  ounces  of  the  solution  are  to  be  used,  and,  after  thorough  disten- 
tion and  gentle  kneading  for  the  sake  of  even  distribution,  the  remnant  should  be  permitted  to 
escape  through  the  cannula. 


274  EULES  OF  ASEPTIC  AND  ANTISEPTIC  SUEGEEY. 

Cold  abscesses  situated  in  the  vicinity  of  accessible  foci,  as,  for  instance, 
near  the  ribs,  scapula,  or  about  the  extremities,  can  be  treated  much  more 
radically.  They  should  be  incised  to  their  full  extent,  and  their  pyogenic 
membrane  aud  cheesy  contents  should  be  scraped  away  until  bleeding, 
healthy  tissue  is  reached.  After  this,  the  fistula  leading  from  the  abscess 
to  the  bone  is  searched,  and  the  exact  location  of  the  diseased  bone  is  ascer- 
tained. 

The  treatment  of  the  affection  of  the  bone  consists  in  free  exposure  and 
thorough  removal  of  all  portions  that  are  manifestly  in  a  state  of  ulceration 
or  cheesy  degeneration.  The  foci  are  made  accessible  by  a  free  use  of  the 
chisel  and  mallet.  The  sharp  spoon  and  gouge  must  clean  out  the  last 
vestige  of  granulating  or  cheesy  tissue,  until  the  bone  presents  a  healthy 
and  fresh  surface.  Finally,  the  external  wound  is  closed  by  suture,  due 
regard  being  paid  to  drainage,  and  the  parts  are  dressed  aseptically.  Thus 
primary  union  of  the  entire  wound  may  be  accomplished. 

The  following  example  may  serve  as  an  illustration  : 

Case. — Herman  Mehle,  barber,  aged  twenty-nine.  Large  cold  abscess  of  inter- 
scapular space  of  dorsum,  extending  under  the  left  scapula.  January  8,  1885. — In- 
cision, evacuation,  and  scraping  of  the  cavity.  A  sinus  leading  toward  the  transverse 
processes  of  the  second  and  third  thoracic  vertebrae  was  followed  up  by  incision,  and 
led  to  a  number  of  small  sequestra  belonging  to  the  heads  of  the  second  and  third  ribs. 
They  were  removed  by  gouging,  and  the  abscess  was  closed  by  suture.  Relapse  of  the 
cicatrices  required  renewed  scrapings.     March  18th. — Patient  was  discharged  cured. 

Revision — that  is,  exploration  and  supj)lementary  removal  of  overlooked 
tuberculous  masses  by  gouging  and  scraping — is  a  very  necessary  and  per- 
fectly harmless  measure,  that  should  be  employed  within  three  or  four 
weeks  after  the  primary  operation,  in  case  the  remaining  sinuses  show  no 
tendency  to  heal.  The  appearance  of  exuberant  ulcerating  granulations 
about  the  orifices  of  the  drainage-holes  should  be  loohed  upon  as  an  urgent 
indication  for  revision.  Anaesthesia  can  be  rarely  dispensed  with  on  these 
occasions. 

Tuberculous  foci  in  the  vicinity  of  a  joint  are  a  great  menace  to  its  sound- 
ness. Early  detection  and  timely  evacuation  will  have  the  character  of  a 
truly  conservative  step.  The  diagnosis  of  a  single  and  central  cheesy  focus 
of  a  long  bone  is  not  easy  to  make  ;  but  the  lymphatic  habit  of  the  patient, 
the  local  swelling  of  the  bone,  with  elevation  of  the  local  temperature  and 
distinct  spontaneous  and  pressure  pain,  may  serve  as  valuable  guides  to  its 
correct  ascertainment.  Slight  stiffness  of  the  Joint  nearest  to  the  focus  in 
the  morning,  with  a  hardly  noticeable  limp,  which  becomes  more  marked 
toward  night,  are  significant  warnings  portending  the  gradual  breaking 
down  of  the  remnant  of  bone-tissue  serving  as  a  barrier  against  the  inva- 
sion of  the  joint. 

Where  cheesy  foci  are  suspected  in  the  vicinity  of  a  joint,  probatory  in- 
cision and  exploration  are  justified. 

In  cases  where  the  increasing  swelling  of  the  bone,  a  cold  abscess,  or  the 
presence  of  sinuses  with  fever  admit  no  doubt  regarding  the  nature  of  the 


TREATMENT  OF  TUBERCULOSIS. 


2Y5 


trouble,  free  incision  and  exposnre  by  chisel  and  mallet  must  be  practiced, 
followed  by  a  painstaking  removal  of  all  degenerated  tissues,  sequestra,  and 
cheesy  deposits.     The  subsequent  treatment  of  these  wounds  is  identical 
with  that  advised  after  necrotomy  for  osteomyelitic  sequestra. 
6.  Tuberculosis  of  Joints.    White  Swelling : 


General  Part. 

Typical  tuberculous  arthritis,  caused  by  pei'foration  of  an  epiphyseal 
cheesy  focus  into  the  joint,  or  by  an  independent  infection  of  the  synovial 
membrane  from  a  distant  focus  (bronchial  glands)  by  way  of  the  general 
circulation,  is  popularly  known  as  ivliite  sivelling.  Mild  cases  of  children, 
treated  by  an  invigorating  regimen 


PS* 
-5S'-      .0-.     yf, 


^  % 


Fig.  201. — Giant  cell  containinfc  two  bacilli 
from  t'uno-oid  grauulations  of  the  capsule 
of  the  hip-joint  in  morbus  coxarius  (700 
diameters).     (Koch.) 


and  proper  orthopedic  measures,      '  ,=r^  l^     •-^•■;.  j^^ 

will  yield  very  good  results  with- 
out serious  operative  interference. 

Even  when  "  starting  j)ains  " 
indicate  loss  of  the  cartilaginous 
covering  and  caries  of  the  joint 
surfaces,  a  cure  by  anchylosis  or 
with  the  preservation  of  more  or 
less  mobility  is  jDossible.  Small  or 
great  periarticular  abscesses,  in- 
cised and  drained  under  aseptic 
cautelaB,  will  heal  kindly,  and  the 
ingrafting  of  the  more  intense  pu- 
rulent infection  upon  tissues  whose 
power  of  resistance  has  been  low- 
ered by  tuberculosis  and  disuse, 
will  be  avoided.  A  careless  incis- 
ion, or  a  sijontaneous  perforation,  on  the  other  hand,  is  generally  the  start- 
ing-point of  widespread  destruction,  caused  by  suppurative  infection  from 
without.  Then,  to  conserve  the  limb  or  life  of  the  patient,  the  diseased 
Joint  must  often  be  sacrificed. 

a.  Technique  of  Joint  Exsection. — The  technical  rules  to  be  ob- 
served in  excising  joints  are  governed  by  the  following  requirements  : 

(a)  Septic  infection  from  tvitJwut  must  he  excluded  by  strict  adherence 
to  the  rules  of  asepticism.  If  a  local  septic  condition,  due  to  purulent 
infection  by  uncleanly  management  of  a  cold  abscess  or  sinus,  be  present, 
this  has  to  be  first  eliminated  by  free  incision  and  drainage  of  burrowing 
phlegmonous  collections  and  by  frequent  irrigation.  Only  after  the  return 
of  the  temperature  to  nearly  the  normal  standard  is  exsection  permissible. 

Note. — ^Phlegmonous  inflammation  of  a  tuberculous  joint  is  a  much  more  serious  trouble 
than  that  of  a  previous  healthy  joint.  The  cavities  and  sinuses  preformed  by  the  tuberculous 
process  serve  to  disperse  the  new  poison  much  more  rapidly  and  widely  than  would  otherwise 
be  the  case.  Hence  the  formation  of  perforations  and  burrows  up  and  downward  between  the 
muscles  of  the  extremity  occurs  much  sooner  in  tuberculosis  than  happens  with  a  previously 


276  RULES  OP  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

normal  capsule.  The  typical  mode  of  incision  and  drainage  of  the  knee-joint,  for  instance,  will  be 
found  insufficient  in  this  contingency,  and  multiple  perforation  into  the  popliteal  space  will  read- 
ily occur.  Exsection  of  a  knee-joint  subject  to  the  ravages  of  both  tuberculosis  and  intense 
phlegmon  will  offer  very  slender  chances  of  success,  and  amputation  will  have  to  be  decided  on. 

The  preservation  of  asepticism  is  greatly  promoted  by  almost  continuous 
irrigation  of  the  wound  during  the  time  of  operation.  Corrosive  sublimate 
(1  :  1.000)  can  be  fearlessly  used  for  any  length  of  time  ivliile  Es.marcli's  con- 
strictor is  in  situ,  as  no  absorption  is  thus  possible  (Woelfler).  In  exsec- 
tions  done  luitJiout  artificial  ancemia,  very  tueah  solutions  of  corrosive 
sublimate  {1  :  5,000)  or  Thiersch'' s  lotion  should  be  employed.  At  the  con- 
clusion of  the  operation,  however,  the  wound  should  be  well  flushed  with 
stronger  (1  :  1,000)  corrosive-sublimate  solution. 

{b)  Removal  of  all  parts,  soft  or  osseous,  that  are  manifestly  diseased, 
whether  carious,  cheesy,  gelatinous,  or  granulating,  is  a  most  important 
condition  of  success.  On  the  other  hand,  no  apparently  healthy  parts  ought 
to  be  needlessly  sacrificed. 

Note. — Without  antiseptics  joar^zaZ  excisiotis  of  joints  were  much  more  dangerous  than  total 
ones.  The  reason  of  this  was  the  fact  that  after  total  excision  the  conditions  for  effective  drainage 
were  much  better  than  after  partial  exsections.  Suppuration  of  resection  wounds  was  the  rule 
then,  and  is  now  the  exception,  hence  partial  excisions  are  just  as  safe  at  present  as  total  ones. 

To  prevent  further  dissemination  of  the  tubercular  virus  from  the  site 
of  the  operation,  ample  incisions  must  be  made.  They  will  enable  the  sur- 
geon to  reach  every  part  of  the  diseased  Joint  without  the  employment  of 
undue  force  by  retractors. 

Diseased  bones  are  removed  by  the  saw  in  adults  ;  in  children,  they  can 
be  pared  off  with  a  strong  scalpel.  Pockets  filled  with  caseous  matter  are 
scooped  out  with  the  sharp  spoon.  The  entire  capsule  must  be  removed  by 
dissection  ivith  curved  scissors  and  a  mouse-tooth  forceps. 

(c)  To  control  haemorrhage,  artificial  anaemia  should  be  used  during  the 
operation  wherever  possible.  Where,  as  in  the  shoulder-  and  hip-joints, 
Esmarch's  band  can  not  be  well  applied,  each  vessel  must  be  secured  and 
tied  as  soon  as  it  is  exposed  or  cut. 

Artificial  ancemia  may  be  kept  up  till  the  dressings  are  completed ;  but 
care  must  be  taken  to  search  out  and  tie  every  cut  vessel  before  closing  the 
wound.  How  to  do  this  is  described  in  the  paragraph  on  artificial  anaemia 
in  amputations  (page  66). 

{d)  Preservation  of  the  usefulness  of  the  limb,  or  of  the  function  of  the 
exsected  joint,  is  the  last,  but  not  least,  requirement  to  be  fulfilled. 

The  knee-  and  occasionally  the  hij)-joint  will,  as  a  rule,  be  more  useful 
if  firmly  anchylosed  than  otherwise.  Mobility  of  the  other  joints,  however 
limited,  is  more  desirable  than  anchylosis. 

To  favor  anchylosis,  the  sawed  surfaces  of  the  bones  to  be  united  must 
be  brought  and  kept  in  firm  apposition  by  posture,  suture  or  nails,  and  a 
contcntive  dressing. 

Where  preservation  of  mobility  is  aimed  at,  the  periosteal  covering  of 
the  exsected  bones  must  be  preserved  by  subperiosteal  dissection.     The  peri- 


TREATMENT  OF  TUBERCULOSIS.  277 

ostenm  can  be  strii:>i)ed  off  easily  with  an  elevator  or  Sayre's  "oyster-knife," 
except  at  the  site  of  the  insertion  of  muscles,  where  the  aid  of  the  scalpel 
or  a  sharp  rasi)atory  must  be  accepted.  The  re-formation  of  the  normal 
contour  and  function  of  the  prospective  joint  depends  in  a  great  measure 
upon  the  preservation  of  the  periosteum. 

With  drainage  by  rubber  tubes,  an  exact  suture  of  the  external  wound, 
and  Schede's  modification  of  the  aseptic  dry  dressing,  the  operation  is  com- 
pleted. Where  Esmarch's  constricting  band  was  left  m  situ  until  the  com- 
pletion of  the  dressings,  these  must  be  made  rather  ample,  and  a  good  deal 
of  elastic  pressure  by  snug  bandaging  must  be  brought  to  bear  upon  the 
wound  to  control  oozing  and  soiling  of  the  dressings.  The  dressed  limb 
must  be  suspended  or  otherwise  elevated  in  a  vertical  position  until  the 
hyperemia  due  to  vascular  paresis  disappears.  Care  must  be  taken  to  ascer- 
tain, by  the  look  of  the  tips  of  the  toes  or  fingers,  that  circulation  is  not 
wholly  cut  off  by  strangulating  compression  of  the  bandage. 

Should  the  oozings  penetrate  the  dressing  in  the  course  of  a  few  hours, 
the  soiled  surface  of  the  bandage  must  be  thickly  dusted  with  iodoform  pow- 
der to  favor  exsiccation.  A  few  compresses  of  sublimated  gauze  are  placed 
over  the  bloody  spots,  and  are  secured  by  a  few  turns  of  a  roller  bandage. 

In  case  of  continued  oozing,  further  loss  of  blood  can  be  checked  by  the 
temporary  application  of  a  Martin's  elastic  bandage  over  the  dressings.  If 
the  soiling  is  too  extensive  to  admit  the  use  of  such  partial  measures  as 
those  just  indicated,  the  external  compresses  composing  the  dressing  must 
be  removed  and  replaced  by  clean  ones.  The  deepest  part  of  the  dressing, 
hoioever,  should  not  he  disturhed. 

~b.  Aftee-Treatment. — Where,  as  for  instance,  in  the  elbow,  mobility 
of  the  joint  is  aimed  at,  absolute  fixation  by  splint  should  continue  only  so 
long  as  the  drainage-tubes  are  withdrawn  and  the  incisions  are  firmly 
healed.  Passive,  but  especially  early  passive  motions,  so  warmly  recom- 
mended by  older  authors,  are  harmful,  and  not  to  be  compared  as  regards 
their  value  with  active  exercises. 

The  disadvantages  of  early  passive  motions  can  be  summed  up  in  this  : 
Before  the  re-establishment  of  the  normal  condition  of  the  tissues  pertain- 
ing to  an  exsected  joint — that  is,  before  the  disappearance  of  the  swelling 
and  rigidity  of  the  soft  parts — all  motions,  active  and  passive,  will  be  pain- 
ful. Active  motions  will  be  limited  to  a  harmless  compass  by  the  pain  for- 
bidding extensive  movements  ;  but  passive  motions,  done  without  regard  to 
the  pain  and  struggles  of  the  resisting  patient,  will  be,  and  as  a  matter  of 
fact  often  are,  carried  far  beyond  the  limit  of  harmlessness.  The  forcible 
stretching  and  crushing  together  of  the  newly  united  parts  and  of  the  young 
connective  tissue  are  inevitably  followed  by  minute  ruptures  and  lacerations. 
Eenewed  exudation  and  a  diffuse  state  of  adhesive  inflammation  are  set  up, 
which  will  cause  the  persistence  or  even  an  increase  of  the  painful  swelling 
and  induration  primarily  found  about  the  exsected  joint.  The  greater  the 
surgeon's  energy  the  worse  the  result,  and  in  many  cases  anchylosis  is 
brought  on  by  the  very  measures  intended  to  2:)revent  it. 
37 


278 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


If  tli9  surgeon,  on  the  other  hand,  patiently  awaits  the  time  of  spontane- 
ous detumescence,  which,  with  antiseptic  measures  and  proper  fixation,  will 
occur  at  ahout  the  fourth  or  fifth  week  after  the  operation,  gentle  motions 
will  cause  no  pain,  and  will  encourage  the  patient  to  active  exercise  of  the 
joint.  The  pain  felt  on  excessive  movement  will  serve  as  a  wholesome 
check  against  undue  zeal  ;  the  improvement  of  nutrition  due  to  active  exer- 
cise will  hasten  the  definitive  involution  of  the  inflammatory  products. 
Thus,  day  by  day  will  the  strength  and  amplitude  of  the  active  movements 
be  increased,  and  by  dint  of  painless  attrition  new  articular  surfaces  will  be 
ground  and  polished  into  shape.  The  psychological  and  moral  part  of  the 
after-treatment  is  of  the  greatest  imjjortance  here.  The  conviction  that 
active  movemefits  of  the  exsected  joint  are  possible  without  pain  will  inspire 
the  patient  with  courage.  Unceasing  active  exertion  will  work  wonders, 
based  upon  the  patient's  confident  expectation  of  a  good  final  result. 

The  acute  pain  produced  by  frequent  and  merciless  passive  motion,  and 
the  subsequent  tenderness  engendered  by  it,  will  convert  the  after-treatment 
to  a  source  of  constant  terror  and  moral  depression  to  the  patient.  His 
courage  will  be  shattered,  and  no  amount  of  persuasion  or  coercion  will  in- 
duce him  to  inflict  pain  upon  himself  by  active  movements.  And  it  will 
be  a  lucky  circumstance  if  the  physician's  illy  conceived  attempts  at  estab- 
lishing a  normal  function  are  frustrated  at  an  early  date  by  the  patient's 
resistance.  Subsequently,  rest  and  the  disappearance  of  local  j)ain  will 
naturally  elicit  first  timid,  later  bolder,  attempts  at  active  movement,  and 
after  all,  an  unexpectedly  good  function  may  thus  result. 

The  aid  afforded  to  Nature  should  be  very  discreet  indeed,  here  as  well 
as  in  other  branches  of  surgery. 

Aside  from  active  movements,  massage  and  faradism  are  powerful  aids 

in  re-establishing  normal 
circulation  and  lost  mus- 
cular power. 

Special  Part. 

a.   Shoulder  -  JoiKT. 
— The  application  of  arti- 
ficial angemia  in  exsection 
of  the  shoulder- joint  is  al- 
ways difficult  and  some- 
times   entirely    impracti- 
cable.    After  due  cleans- 
ing   and    disinfection    of 
the  field  of  operation,  the 
hand  and  forearm  of  the 
affected    limb   are   envel- 
oped in  a  clean  towel  wrung  out  of  mercuric  lotion  (Fig.  202),  and,  the 
rest  of  the  body  being  well  protected  by  rubber  sheets  and  clean  towels,  an 
ample  anterior  incision  is  carried  from  midway  between  the  acromion  and 


l^'iG.   202. — Exsection  of  slioulder-johit.     Head  of  humerus 
turned  out  of  glenoid  cavity. 


TREATMENT  OF  TUBERCULOSIS. 


279 


Fig.  203. 


-Exsection  of  shoulder-joint.     Location  of  drainage  on 
the  posterior  as23ect  of  the  shoulder. 


the  coracoid  process  down  to  the  limit  of  the  upper  third  of  the  humerus. 
The  tendon  of  the  long  head  of  the  biceps  is  held  aside  by  a  blunt  hook. 
The  capsular  ligament  and  periosteum  are  raised 
from  the  bone  by  means  of  an  elevator,  or,  where 
the  insertions  of  the  muscles  offer  greater  resistance, 
by  a  sharp  raspatory.  This  step  will  be  very  much 
facilitated  by  gradual  inward  and  later  by  outward 
rotation  of  the  humerus,  to  be  done  by  an  assistant 
holding  the  hand  and  bent  elbow.  After  decapita- 
tion of  tlie  humerus, 
the  capsule  is  to  he 
exsected  iy  forceps 
and  blunt  scissors. 
This,  the  most  diffi- 
cult part  of  the  o])- 
eration,  will  be  very 
easy  if  the  primary 
incision  is  ample.  If 
found  diseased,  the 
glenoid  fossa  is-thor- 
oughly  scra^jed,  and, 
a  counter-incision  being  made  at  the  posterior  aspect  of  the  joint,  a  drain- 
age-tube is  inserted  there.  (Fig.  203.)  The  first  incision  is  closed  by  several 
tiers  of  catgut  sutures,  and,  the  wound  being  dressed,  the  limb  is  bandaged 
to  the  thorax  in  a  flexed  position.  Later  on,  an  arm-sling  will  serve  as  an 
adequate  support.     (Figs.  204  and  205. ) 

The  dressings  are  changed  on  the  tenth  day,  when  the  drainage-tube 
can  also  be  removed.  In  grown  subjects  the  operation  will  generally  result 
in  a  somewhat  loose  joint,  lacking  especially  the  power  of  active  abduction. 

Case  L— Anna  Haupt,  aged  sixty.  Large  subdeltoid  cold  abscess;  no  fistula. 
May  S5,  1879. — Exsection  of  right  shoulder-joint  at  the  German  Hospital.  Head 
of  humerus  bare  of  cartilage  and  carious ;  caries 
of  glenoid  cavity.     August  3d. — Discharged   cured. 

Case  II. — Willie  Kunz,  aged  four. 
January  S5,  1882. — Exsection  of  left 
shoulder-joint  for  cheesy  osteitis  of  the 
head  of  humerus  at  the  German  Dis- 
pensary. March  10th. — Discharged 
cured. 

Cask  III.—  August  Arnold,  aged 
three  and  a  half  years.  April  17, 
1883.— 'Exsection  of  left  shoulder- 
joint  for  caseous  foci  in  the  head  of 
the  humerus  at  the  German  Hos- 
pital.  May  30th. — Discharged  cured. 

Case  IV. — Harry  Gross,  aged  two.  September  30,  1884-  —  Exsection  of  right 
shoulder-joint  for  caseous  osteitis  at  Mount  Sinai  Hospital.     Several  relapses  required 


•204. — First  dressing  after  exsection  of 
shoulder-joint. 


280 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  205 


renewed  scraping  of  the  fungous  granulations.     January  15,  18S5. — Patient  died  of 
meningeal  and  peritoneal  tuberculosis  with  ascites. 

Case  V. — Carl   Buchowsky,  type-setter,   aged  twenty-eight.      Synovial   tubercu- 
losis of  right  shoulder-joint  of  six  yeai's' 

standing;  three  tistulse.     April  £6,  1887.  j 

— Exsection  of  the  shoulder-joint  at  the  "^ 

German  Hospital.  In  May  patient  was 
discharged  not  cured,  with  two  fistulse, 
but  with  a  very  fair  prospect  of  an  ulti- 
mate cure,  the  cause  of  his  discharge  be- 
ing a  disciplinary  breach  of  the  rules  of 
the  hospital. 

l.  Elbow. — The  patient's  shoul- 
der, hand,  and  part  of  his  forearm 
are  wrapped  in  clean  towels  soaked 
in  corrosive-sublimate  lotion.  (Fig. 
206.)  The  arm  is  vertically  elevated 
for  a  few  minutes,  and  elastic  con- 
striction is  applied  to  the  humerus 
below   the   shoulder.     Langenbeck's 

posterior  longitudinal  incision  will  give  most  space.  (Fig.  207.)  In  denud- 
ing the  internal  epicondyle,  injury  of  the  ulnar  nerve  should  be  guarded 
against  by  closely  hugging  the  bone  with  the  instrument.  The  diseased 
portions  of  the  bones  being  removed,  the  entire  capsular  ligament  is  ex- 
sected,  care  being  taken  not  to  overlook  any  cheesy  foci. 
One  or  more  drainage-tubes  are  inserted,  preferably 
through  pre-existing  sinuses,  and  the  incision  is  closed 
by  catgut  sutures.  The  region  of  the  elbow  is  envel- 
oped in  an  ample  Schede's  dressing,  held  down  by  rather 
tight  bandaging.    The  extended  arm  is  fastened  to  a  pair 

of  lateral  paste- 
board splints, 
and  is  kejjt  in 
the  vertical  po- 
sition till  the 
flushed  appear- 
ance of  the  pro- 
jecting tips  of 
the  fingers  due 
to  vascular  pa- 
ralysis   has    dis- 


Exscetion  of  cll)ow-joint.     I'atient  ready  for  operation. 


appeared.     (Fig- 
208.) 

Note. — The  simplest  way  of  makinf;;  suitable  pasteboard  splints  is  by  tearing  them  out  of  a 
sheet  of  pasteboard.  (Fig.  209.)  The  advantage  of  tearing  over  cutting  is  in  the  circumstance 
that  tlie  edges  of  the  torn  splint  are  not  abrupt  and  hard,  hut  become  soft  and  thin  on  account 
of  the  gradual  thinning  of  the  torn  edge.    Snug  adaptation  and  a  good  lit  result  therefrom.    Care 


TREATMENT  OF  TUBERCULOSIS. 


281 


must  be  taken  to 
ascertain  first  the 
trend  of  the  fiber 
of  the  pasteboard, 
as  the  edge  of  the 
splint  torn  across 
the  direction  of 
the  fiber  will  turn 
out  uneven,  and  a 
splint  thus  made  is 
apt  to  break. 

The  dress- 
ings should  be 
changed,  and 
the  drainage- 
tubes  removed, 
a  fortnight  aft- 
er the  exsection. 
The  elbow  is 
to  be  re-dressed 
and  put  up  at 
the  same  angle. ' 

As  soon  as  the  drainage-holes  are  healed,  passive,  but  especially  active,  exer- 
cises should  commence,  aided  by  massage  and  faradism  applied  to  the  muscles. 
After  partial  exsection  of  the  joint,  little  lateral  mobility  will  be  observed. 
In  these  cases  no  special  apparatus  will  be  required.  But  where  much  lateral 
mobility,  due  to  extensive  removal  of  bones,  is  present,  the  use  of  an  apini- 
ratus  confining  the  movements  of 
the  joint  to  flexion  and  extension 
will  be  required.     (Figs  212,  213.  \ 


Fig.  207. — Posterior  longitudinal  nicision  ot  elbow-joint. 


Fig.  208. — Finished  dressing  and  eleva- 
tion after  exsection  of  elbow-joint. 


Ftg.  209.— Tearinif  into 


of  pasteboard  splint. 


XoTE. — The  apparatus  can  be  Tuade  by  the  surgeon  without  the  aid  of  the  instrument-maker 
in  the  following  manner :  Two  strips  of  very  light  hoop-iron  or  sheet  zinc,  about  one  inch  wide 


2S2 


KULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


and  from  four  to  six  inches  long,  are  loosely  riveted  to  each  other  at  their  ends,  so  as  to  form  a 
hinge.  Two  pairs  of  such  hinges  are  necessary.  The  patient's  arm  being  protected  by  a  few 
turns  of  a  flannel  bandage,  a  light  silicate-of-soda  wristlet  and  arm-band  (Fig.  212)  are  applied. 
To  these  are  fitted  the  hinges,  one  externally,  the  other  internally,  by  giving  their  middle  a  suitable 
bend  to  allow  for  the  expansion  of  the  soft  tissues  on  flexion  of  the  joint  (see  front  view).     By 


Fig.  210. — Pattern  for  angular  pasteboard  splint.     (Esmarch.) 

a  few  more  turns  of  the  silicate  bandage,  the  hinges  will  become  immured  in  the  wristlet  and 
arm-band.  As  soon  as  the  splint  is  dry,  it  is  split  longitudinally  on  its  anterior  aspect,  to  per- 
mit its  removal  and  further  fitting.  Shoe  eyelets  are  put  in  along  the  edges  of  the  longitudinal 
cuts  for  lacing.  Two  pairs  of  small-sized  brass  screw-eyes  are  let  in  on  each  side  of  the  wristlet 
and  arm-band,  to  serve  for  the  attachment  of  solid  rubber  bands,  which  are  to  aid  the  efforts  of 
the  flexor  muscles  in  bending  the  elbow.  To  prevent  slipping  down  of  the  apparatus,  a  cap  is 
made  of  a  piece  of  sole-leather,  softened  in  hot  water,  which  is 
molded  to  the  shoulder.  It  is  left  on  till  dry.  A  button  is  let 
into  it  to  serve  for  suspending  from  it  the  apparatus  by  a  short 
strap.  Another  strap  slipped  over  this  button  is  passed  ai'ound  the 
thorax  of  the  patient,  and  is  buckled  in  the  opposite  axilla.  (Fig.  213.) 
Flexion  and  extension  are  to  be  done  by  the  patient  at  regular 
intervals  from  six  to  eight  times  a  day,  by  raising  first  an  empty  pail 
from  the  ground  twenty  or  thirty  times.  The  elbow  flexed  by  the 
rubber  bands  is  extended  by  the  weight  of  the  pail.    As  the  strength 


Fig.  211. — Angular  pasteboard  splint  in  sitn.     (Esmarch.) 


of  the  flexors  improves,  active  flexion  is  to  be  tried,  and  the  weight  of  the  pail  is  to  be  gradu- 
ally increased  by  putting  more  and  more  sand  or  gravel  into  it.  The  apparatus  is  to  be  daily 
removed,  for  cleansing  and  the  application  of  massage  and  faradism  to  the  arm.  The  use  of 
the  apparatus  can  be  abandoned  with  the  disappearance  of  lateral  mobility. 

The  first  of  the  nine  cases  of  exsection  of  the  elbow-joint  performed  by 
the  author  was  done  witliout  aseptic  precautions.  Study  of  the  history  of 
this  case  and  comparison  with  tlie  other  cases  is  earnestly  recommended  to 
the  reader. 


TREATMENT  OF  TUBERCULOSIS. 


283 


Case  I. — Jose[ili  Keck,  silk-weaver,  aged  tliirty-uine.  Synoviiil  tuberculosis  of 
riglit  elbow,  with  cold  abscess  situated  beneath  the  supinators;  no  fistula.  iJecemher 
10,  1877. — Total  exsection  of  the  joint  at  the  rooms  of  the  patient 
without  any  aseptic  precautions.  Trochlea,  ulna,  and  radius  ca-  ^\^ 
rious.  Drainage,  suture,  and  suspension  in  an  interrupted  wire 
s|)lint.  Wound  was  dressed  with  a  compress,  to  be  kept  moist  by 
immersion  in  tepid  water.  The  thermometer  indicated  103°  Fahr. 
on  the  evening  of  the  same  day,  and  never  descended  below  this 
figure  until  December  24th.  Frequently  the  temperature  rose  to 
1(»5°  Fahr,  Decemher  13th. — Wound  fetid,  inflamed,  suppurating; 
stitches  were  removed,  whereupon  the  wound  gaped  open,  and  was 
seen  to  be  covered  with  a  thick,  adherent  coating.  December  15th. 
— Great  swelling  and  dusky  appearance  of  cubital  region.  Incision 
of  abscess  near  triceps  tendon.  Decemher  17th. — Rigor,  elbow  still 
more  swollen.  December  18th. — Rigor.  December  19th. — Rigor 
and  great  debility.  December  22d. — Rigor.  December  2Ji.th. — 
Evacuation  of  another  abscess  from  the  upper  angle  of  the  wound, 
whereiipon  the  temperature  fell  to  99°  Fahr.,  and  the  dusky  swell- 
ing of  the  limb  moderated.  Apparently  the  fever  was  due  to  osteo- 
myelitis of  the  lower  end  of  the  humerus.  December  25th. — Ery- 
sipelas set  in,  commencing  from  an  abrasion  caused  by  the  splint. 
Temperature,  105°  Fahr.  December  29th. — Erysipelas  extended  to 
shoulder-joint,  where  it  disappeared.  March  10th. — Incised  three 
abscesses  of  the  forearm,  wound  granulating  and  contracting;  re- 
moval of  sequestrum  of  humerus.  June  Ufth. — Removal  of  six 
small  sequestra  from  humerus.  Active  and  passive  movements  com- 
menced.    July  12th. — Flexion  to  90°;  extension  normal.     Sinuses 

were  scraped  in  anesthesia. 
Lateral  mobility  diminishing. 
September  29th. — Api)lication 
of  articulating  apparatus.  Oc- 
tober 30th. — Patient  was  dis- 
charged cured  with  normal 
flexion  and  extension,  with 
limited  pronation  and  supina- 
tion, and  slight  lateral  mobil- 
ity. May.,  1887. — Arm  sound 
and  quite  useful,  in  spite  of  slight  lateral  mo- 
bility. 

Case  II. — Hermann  Prieg,  laborer,  aged  thir- 
ty-eight. November  15,  1880. — Total  exsection 
of  elbow-joint  at  the  German  Hospital  for  syn- 
ovial fungous  disease  with  fistula,  under  anti- 
septic precautions.  Feverless  course,  primary 
union.  February  27th. — The  patient  was  dis- 
charged cured,  with  limited  motion  and  no  lat- 
eral mobility. 

Case  III. — Lena  Bois,  aged  twelve.  March 
14,  1882. — Partial  exsection  of  elbow-joint  for  caseous  ostitis  of  the  olecranon,  from 
which  a  sequestrum  was  removed  at  the  German  Hospital.  April  30th. — Discharged 
cured  with  limited  motion. 


Fig.  212.— Appara- 
tus for  after-treat- 
ment of  exsection 
of  elbow-joint. 


Fig. 


213. — Elbow-joint  apparatus  in 
position. 


284  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Case  IV. — Theodore  Noirot,  metal- woi'ker,  aged  twenty-eight.  March  9^  1882. — 
Total  exsection  of  elbow-joint  at  the  German  Hospital  for  osseal  tuberculosis  of 
humerus,  ulna,  and  radius.  Primary  union  of  the  deep  parts  of  the  wound.  May  9th. 
—  Disciharged  cured  with  almost  perfect  function  of  the  new  joint. 

C.vsE  V. — Leonhard  Path,  aged  seven.  Cheesy  tuberculosis  of  olecranon.  October 
Slst. — Partial  excision  at  Mount  Sinai  Hospital.  Novemher  10th. — Discharged  cured 
with  limited  motion,  which  improved  somewhat  in  the  course  of  the  following  six 
months. 

Case  VI. — Luigi  Martini.  May  S7,  1886. — Total  exsection  for  osseal  tuberculosis 
of  humerus,  ulna,  and  radius  at  the  German  Hospital.  Primary  union.  June  6th.— 
Discharged  cured  with  limited  motion.  Owing  to  neglect  of  the  parents,  who  failed 
to  present  the  boy  for  after-treatment,  the  joint  became  almost  entirely  stiff. 

Case  VII. — Charles  Dunninger,  aged  two  and  a  half.  A2}rU  2%,  1886. — Total  ex- 
section  for  extensive  osseal  tuberculosis  at  the  German  Hospital.  Primary  union  and 
ultimately  excellent  function.  Discharged  cured  August  1st.  The  discharge  was 
delayed  by  the  inability  of  the  parents  to  take  care  of  the  child. 

Case  VIII. — Nathan  Blumenbach,  aged  seven.  Extensive  osseal  tuberculosis  with 
several  abscesses.  February  9,  1886. — Incision  and  drainage  of  the  abscesses,  followed 
by  severe  chill  and  fever,  very  likely  due  to  septic  infection  at  the  time  of  the  incision. 
February  11th. — Total  exsection  at  the  Gennan  Hospital,  followed  by  prompt  low- 
ering of  the  temperature  from  105°  Pahr.  to  99°  Pahr.  Primary  union.  Marcli  ll^th. — 
Discharged  cured,  with  good  function. 

Case  IX. — Rudolph  Boenke,  aged  twelve.  Cheesy  osteitis  of  olecranon  vrith 
abscess.  March  30th. — Partial  excision.  A  shell  of  the  olecranon  adhering  to  the 
triceps  tendon  was  preserved.  Suture ;  no  drainage-tubes.  April  12th. — Change  of 
dressings;  primary  union.  Elbow  put  up  at  a  right  angle.  April  IJ^th. — Passive 
motion ;  fixation  at  an  acute  angle.  Every  few  days  passive  motions  were  done.,  and 
the  arm  was  put  up  at  a  different  angle.  This  led  to  considerable  irritation  and  dense 
oedema  of  the  elbow,  compelling  cessation  of  the  passive  movements.  The  mistake 
made  in  the  after-treatment  was  further  emphasized  by  the  detachment  and  expulsion 
of  the  necrosed  remnant  of  the  olecranon.  Two  fistulse  discharging  bloody  serum 
remained  open.  May  30th. — The  fistulse  were  scooped  out  with  the  sharp  spoon.  No 
improvement  following,  June  10th,  the  wound  was  reopened  in  ether  anesthesia. 
Gelatinous  infiltration  of  the  soft  parts  surrounding  the  joint,  tuberculosis  of  the  radio- 
ulnar junction  and  caries  of  the  resected  bone-surfaces  vv'ere  found.  Total  exsection 
being  performed,  the  arm  was  dressed  and  put  up  in  a  splint  as  usual,  and  remained 
undisturbed  for  five  weelcs.,  after  which  active  exercises  were  commenced.  No  passive 
movements  were  done  at  all.  By  August  1st.,  active  flexion  and  extension  were  normal, 
and  the  arm  had  regained  its  power  almost  completely. 

c.  Weist  axd  Hand. — Langeubeck's  dorsal  incision  affords  the  most 
favorable  approach  to  the  radio-carpal  as  well  as  especially  to  the  intercarpal 
and  metacarpo-carpal  joints.  (Fig.  214.)  With  artificial  angemia  a  very 
thorongh  removal  of  the  diseased  bones  and  capsular  ligaments  can  be  done. 
The  wound  is  drained  and  closed  by  catgut  sutures,  and,  being  inclosed  in 
an  aseptic  Schede's  dressing,  the  hand  is  fastened  to  a  short  volar  splint 
of  wood,  loliicli  nlumld  not  extend  beyond  the  metacarpo-plialangeal  joints. 
The  patient  is  directed  from  the  second  day  on  to  practice  active  motions  of 
the  fingers.  This  will  achieve  two  good  purposes.  First,  extreme  atrophy 
of  the  muscles  will  be  prevented  ;  and  secondly,  adhesions  of  the  tendons 


TREATMENT  OF  TUBERCULOSIS. 


285 


Fig.  214.— Langenbeck's  dorsal  incision  for  exsection  of  wrist. 


and  tendineal  anchylosis  will  be  avoided.  The  active  movements,  feeble  and 
hardly  perceptible  at  first,  will  become  visibly  stronger  as  the  healing  pro- 
gresses, and  thus  a 
very  acceptable  degree 
of  usefulness  of  the 
hand  may  be  regained. 

Case  I. — Herman  Ro- 
sengaiden,  clerk,  aged 
thirtj-four.  June  7,  1882. 
— Total  exsection  of  wrist 
at  Mount  Sinai  Hospi- 
tal for  synovial  tubercu- 
losis with  several  fistulse. 
Primary  union.  August 
7th. — Discharged  cured. 
When  leaving,  he  played 
on  an  accordion. 

Case  II. — A  woman, 
aged    thirty-eight.     Au- 
gust 25,  1885. — Total  ex- 
section  of  left  wrist  at  the  German  Hospital.     Primary  union.     September  30th. — 
Discharged  cured,"with  moderate  function. 

Case  III. — Matthew  Dempsey,  laborer,  aged  twenty.  June  22, 1885. — Total  exsec- 
tion of  wrist  for  osseal  tuberculosis  of  carpal  bones  at  Mount  Sinai  Hospital.  Primary 
union  and  very  fair  function  were  secured.  The  discharge  of  the  patient  was  delayed 
till  the  end  of  the  year  by  several  pulmonary  hsemorrhages. 

Case  IV. — Paul  Klein,  laborer,  aged  forty-one.  February  25,  1886. — Total  exsec- 
tion of  wrist  for  osseal  tuberculosis  with  several  fistulse  at  the  German  Hospital.  The 
patient  was  suffering  from  far-gone  pulmonary  phthisis.  Primary  union,  but  speedy 
relapse  of  tuberculosis  in  the  interior  of  the  wound  and  the  cicatrix.  April  11th. — 
Discharged  not  cured. 

Case  V. — Max  Friedmann,  aged  ten.  April  4^^.— Partial  excision  of  wrist-joint 
on  account  of  csseous  osteitis  of  styloid  process  of  ulna,  with  involvement  of  the  radio- 
ulnar and  radio-carpal  joints.  Primary  union.  April  20th. — Discharged  cured,  with 
good  function. 

Case  VI. — Ferdinand  Ohle,  aged  five  and  a  half.  March  22d. — Total  exsection  o± 
left  wrist  at  the  German  Hospital  for  osseal  tuberculosis.  Wound  healed  by  primary 
union.     Patient  remained  in  hospital  for  treatment  of  simultaneous  tubercular  disease 

of  the  knee-joint. 

d.  Hip- JOINT. — The  author's 
very  limited  experience  in  the  op- 
erative treatment  of  hip-joint  dis- 
ease, extending  over 
three  cases  only,  does 
not  afford  suflScient 
material  to  base  any 
trustworthy  conclu- 
sion upon.   Moreover, 

Fig.  215.— Exsection  of  hip-.ioint.     Position  of  patient.  twO  of  the  three  CaSCS 

38 


286 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  216.— Exsection 
of  hiiJ-joint.  Ar- 
rangement of  pro- 
tective cloths. 


Fig.  217. — Completed  dressing  after  hip-joint 
exsection. 

were,  at  the  time  of  tlie  operation, 
healed  by  anchylosis,  as  far  as  the  affec- 
tion of  the  joint  proper  was  concerned. 
They  came  under  the  author's  care  on  account  of  tubercular  processes 
located  on  the  pelvic  bones,  requiring  operative  treatment. 

Case  I. — Albert  Gaiipp,  aged  thirteen.  Anchylosed  hip-joint;  caseous  ostitis  of 
OS  ilium  with  complicated  sinuses  and  pelvic  abscess. 
Avgust  12,  1882. — Incision  and  drainage  of  various  sinus- 
es and  of  the  pelvic  abscess ;  removal  of  a  considerable 
portion  of  the  ilinm  and  os  pubis  with  mallet  and  chisel 
at  the  German  Hospital,  Jan.  21, 
1555.— Discharged  mucli  improved. 
Case  II. — Samuel  Amster,  aged 
ten.  Tubercular  coxitis,  with  sinus, 
of  two  years'  duration.  Decem- 
ber 3,  1885. — Exsection  of  hip-joint 
above  the  trochanters  at  Mount  Si- 
nai Hospital.  Removal  of  the  ace- 
tabulum, wbich  was  found  perfo- 
rated. After-treatment  with  weight 
extension.  January  18  and  26, 
1886. — Revisions  of  wound,  on  ac- 
count of  the  presence  of  exuberant 
granulations  in  the  drainage-tracks. 
May  10th. — Discharged  cured.  In 
November  the  patient  was  readmit- 
ted on  account  of  pelvic  disease.  A 
fistula  had  been  established  below 
the  anterior-superior  spine,  leading 
to  the  inner  aspect  of  the  ilium. 
December  15th.  —  Three  sequestra 
were  removed  by  an  incision  made 
along  the  crest  of  the  ilium.  In 
June,  1887,  the  patient  was  dis- 
charged cured. 

Case    HI. — John    Renk,    aged 
tliirty-nine.      Anchylosis    of    right 


Fig.  218.— Exsection  of  hip- 
joint.  Final  result.  Ante- 
rior view.  (Di.  F.  Lange'.s 
case.) 


Fig.  219.  —  nip-joitit 
exsection.  Lateral 
view.  (Case  of  Dr. 
F.  Lange.) 


TREATMENT  OF  TUBERCULOSIS.  287 

hip-joint  with  shortening  of  limb,  the  result  of  hip  disease  contracted  in  childhood, 
which  was  treated  orthopedically.  No  fistula.  Tuberculous  ostitis  of  ilium  and  adjoin- 
ing part  of  OS  pubis.  March  17,  1887. — At  the  German  Hospital,  exsection  of  great 
trochanter  and  remnant  of  neck  of  thigh  as  a  means  to  gain  access  to  the  diseased 
focus.  An  abscess  was  opened  in  front  of  the  joint,  and,  being  followed  up,  led  to  a 
number  of  sequestra  located  at  the  juncture  of  ilium  and  os  i)ubis,  which  were  removed. 
The  softened  and  broken-down  walls  of  the  cavity  containing  the  sequestra  were  scraped 
and  gouged.  Drainage  and  suture  of  the  wound.  Uneventful  course  of  healing.  In 
August  the  patient  was  still  under  treatment.  A  sinus  persisted  at  the  site  of  the 
operation.  The  discharge  was  vei-y  scanty  and  serous,  however,  promising  early  clos- 
ure.    Anchylosis  firm  again.     Patient  walking  without  support.     Cured  October  1. 

e.  Knee-joint.  —  White  swelling  of  the  knee-joint  in  adults  of  the 
laboring  class  can,  for  various  external  reasons,  rarely  be  treated  by  ortho- 
pedic measures.  In  children,  a  rational  mechanical  and  general  treatment 
will  often  reward  the  patience  and  skill  of  the  physician  by  excellent  results. 
Exsection  of  the  infantile  knee-joint  is  to  be  avoided  as  long  as  possible,  on 
account  of  the  great  shortening  that  is  caused  by  the  removal  of  the  epi- 
physes adjoining  the  knee,  on  which  depends  the  growth  of  the  thigh  and 
tibia.  In  adults  exsection  is  the  shortest  and  safest  way  of  eliminating  the 
tedious  morbid  process,  and  substituting  firm  anchylosis  for  a  useless  joint. 
ArtJiredomy,  or  exsection  of  the  capsular  ligament  alone,  as  suggested  by 
Volkmann,  has  not  been  attended  with  good  success  in  the  experience  of 
the  author.  Two  cases — one  in  an  adult,  the  other  in  a  child — resulted  in 
relapse  of  the  tubercular  affection,  although  great  care  was  taken  in  remov- 
ing the  entire  capsule.     A  third  case  was  permanently  cured. 

Case  I. — S.  Lindholm,  metal-worker,  aged  twenty-seven.     February  28,  1882. — ■ 
Arthrectomy  and  removal  of  the  patella  were  done  for  fungous  arthritis  of  the  knee- 
joint.     Primary  union  of  wound  followed.     March  22d. — A  relapse  occurred  in  the 
cicatrix,  which  gradually  involved  the  articular  aspects  of  the  femur 
and  tibia.     Amputation  of  the  thigh  was  performed  by  Dr.  I.  Adler. 

Case  II. — Fred.  Ohle,  aged  five  and  a  half.  Tubercular  arthritis 
of  the  knee-joint.  January  26,  1887, — Arthrectomy  was  performed 
at  the  German  Hospital.'  March  22d. — Kevision  and  scraping  of  the 
entire  cavity  on  account  of  tubercular  relapse.  In  May  the  boy  was 
still  under  treatment. 

Case  III. — George  Kuhn,  butcher,  aged  twenty-six.  July  6,  1882. 
— Arthrectomy  and  removal  of  carious  patella  was  performed  at  the 
German  Hospital.  ISfoveiiiber  5th. — Discharged  cured  with  slight  mo- 
bility of  joint. 

In  children,  exsection  should  be  strictly  limited  to  the  re- 
moval of  actually  diseased  parts  of  the  bones.  By  Schede's 
plan  of  dressing  the  wound,  the  hollow  space  remaining  be-  Hahn's  supra- 
tween  the  incongruent  joint-surfaces  will  be  filled  up  by  an  Fon^for^exsec- 
organiziug  blood-clot,  and  firm  union  may  be  attained.  tion  of  kuee- 

Case  IV. — Eva  Greenburg,  aged  eight.     Osseal  tuberculosis  of  the 
knee-joint  with  sequestrum  in  the  external  condyle ;  granular  ostitis  of  the  internal 
condyle ;  multiple  cheesy  deposits  in  the  thickened  capsule ;  subluxation  backward  of 


238 


RULES  OF  ASEPTIC  AND  ANTISEPTIC   SURaERY. 


the  tibia  with  rectangular  contraction,     August  IS,  i5S(?.— Partial  exsection  of  knee- 
joint  at  Mount  Sinai  Hospital.     After  the  removal  of  the  sequestrum,  a  deep  recess 

was  left  behind  in  the  intercondy- 
lar notch.  Patella  and  entire  cap- 
sule were  removed ;  the  ham-string 
tendons  were  divided  to  prevent 
recontraction.  The  tibia  was  su- 
perficially pared,  and  the  bones 
were  held  in  apposition  by  a  nail 
driven  diagonally  through  femur  and 
tibia.  Plaster-of-Paris  splint  over 
a  Schede's  dressing.  Several  re- 
lapses in  the  popliteal  space  re- 
quired repeated  scrapings.  The  pa- 
tient had  one  attack  of  erysipelas. 
By  reason  of  these  complications, 
cure  was  delayed.  February  S7, 
1887. — Patient  was  discharged  cured 
with  firm  anchylosis. 

Total  exsection  of  the  knee-joint  is  usually 
done  by  the  author  in  the  following  manner  : 
After  careful  shaving,  scrubbing,  and  disinfec- 
tion of  the  region  of  the  knee,  the  foot  and  leg 
and  the  thigh  of  the  diseased 
clean 


Fig.  221. — Exsection  of  knee- 
joint.  Exposure  of  articular 
planes. 


limb    are   wrapped    in 
towels  wrung  out  of  corrosive- 
sublimate  lotion.     The  limb  is  held  elevated  in  the  ver- 
tical position  for  five  minutes  to  deplete  its  vessels,  and 
the  constricting  elastic  band  is  applied  well  up  near  the 
root  of  the  thigh.     The  knee  is  flexed,  and  an  incision, 
commencing  at  the  middle  of  one  condyle  of  the  femur, 
and  extending  in  a  semicircular  line  above 
the  patella  to  the  middle  of  the  other  con- 
dyle, is  carried  into  the  joint.     (Fig.  220. 

Note.  —  The  transverse  incision 
above  the  patella,  proposed  by  Eugene 
Hahn,  of  Berlin,  has  many  advantages 
over  the  incision  made  below  the  knee- 
pan.  The  chief  one  is  the  free  access 
it  affords  to  the  bursa  of  the  quadri- 
ceps, which  must  be  carefully  exsectcd 
along  with  the  capsule. 

The  crucial  ligaments  are 
cut  close  to  their  attachment 
to  the  femur,  and  the  j)atella, 

semilunar  cartilages,  and  entire  capsule,  together  with  tlie  bursa  of  tlie 
quadriceps,  are  exsected  with  mouse-tooth  forceps  and  curved  scissors. 
Care  must  be  taken  not  to  overlook  some  small   bursa?  situated  behind 


Fill.  2'J2. 
xsection  _  ot 
knee  -  joint. 
A  view  of 
the  sawed 
surfaces.  • 


TREATMENT  OF  TUBERCULOSIS. 


289 


Fig.  223. — Steel  iiui 


Fig. 


224. — Exsection  of  knee-joint. 
view. 


Sutured  wound.     Anterior 


the  head  of  the  tibia,  which  regularly  communicate  with  the  interior  of 
the  joint. 

The  condyles  of  the  femur  are  sawed  off,  the  plane  of  section  correspond- 
ing to  the  transverse  diameter  of  the  epiphysis  of  the  femur.     (Fig.  222.) 

Note. — Disregard  of  tliis 
rule  will  lead  to  anchylosis 
in  the  bow-leg  position. 

The  articular  as- 
pect of  the  tibia  is  sawed  off  at  a  right  angle  to  the  long-  axis  of  this  bone. 

All  visible  orifices  of  vessels  are  secured  by  ligature.     They  can  be  made 

visible  by  compress- 
ing the  vicinity  of 
the  wound  with  both 
hands. 

If  the  transverse 
incision  was  not  made 
long  enough  to  permit 
of  an  easy  arrangement 
of  the  drainage-tubes 
in   the  angles  of  the 

wound,  it  should  be  sufficiently  lengthened.     The  inner  ends  of  the  tubes 

should  reach  into  the  popliteal  space  just  behind  the  sawed  surfaces,  and  the 

tubes  must  not  be  compressed  and  occluded  by  the  tension  of  the  soft  parts 

surrounding  them. 

The  limb  is  placed  upon  a  long  cushion 

covered  with  a  clean  towel  wrung  out   of 

corrosive-sublimate   lotion,    and,    while   the 

sawed  surfaces  are  held  in  exact  apposition, 

two  or  four  long  steel  nails,  previously  well 

disinfected  by  heating  in  an  alcohol  flame, 

are  driven  diagonally 

through   femur  and 

tibia,  so  as  to  firmly 

lock    the    bones    in 

the  desired  position. 

(See   Fig.    79,    page 

84.)    The  cutaneous 

incision  is  united  by 

a  sufficient  number 

of    catgut    stitches. 

The   limb   is   raised 

by  the  foot  from  the 

cushion,     which     is 

then  removed.     Strips  of  disinfected  rubber  tissue  are  slipped  under  the 

safety-pins,  securing  the  ends  of  the  trimmed  drainage-tubes,  and  an  oblong 

compress  of  iodoformed  gauze  is  laid  over  the  entire  line  of  union.     A  suit- 


225. — Exsection  of  knee-joint.     Sutured  wound._    Lateral  view. 
Heads  of  steel  nails  projecting  from  skin. 


290 


EULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


Fig.  226. — Immediate  dressing  of  woimd  after 
exsection  of  knee-joint. 


able  number  of  sublimated  gauze  compresses  are  arranged  around  the  knee- 
joint,  and  two  short  lateral  splints  of  veneer  or  thin  board  are  firmly  band- 
aged on  to  serve  as  a  deep  support.     (Figs.   226  and  227.)      Over  these 

comes  an  ample  external   dressing  of   corrosive- 
sublimate  gauze,  also  firmly  held  down  by  a  gauze 
bandage.     The  towels  are  removed,  and  the  un- 
covered parts  of  the  limb  are  enveloped  in  a  layer 
of  borated  cotton  to  equalize  the  outline  of  the 
extremity.     Two  long,  lateral,  pasteboard  splints, 
held  down  by  a  muslin  or  crino- 
line bandage,  comj)lete  the  dress- 
ing for  children   or  adolescents. 
(Fig.  228. )    The  more  voluminous 
limbs  of  adults  are  better  secured 
by  a  solid  circular  plaster-of- Paris 
splint. 

The  limb  is  vertically  elevated, 

and  the  constricting  rubber  band 

is  removed.    Return  of  circulation 

is  attested  by  the  pink  color  of 

the  toes.     As  soon  as  these  turn  pale,  the  extremity  can  be  brought  into 

the  horizontal  position. 

If  asepticism  was  well  maintained,  little  aseptic  fever  and  no  severe 
pain  will  follow  the  operation.  The  dressings  should  remain  undisturbed 
for  thirty  days,  to  afford  a  good  chance  for  bony  union.  After  thirty  days 
the  splints  and  dressings  can  be  removed,  and  the  nails  and  drainage-tubes 
can  be  withdrawn.     The  remaining  sinuses  are  to  be  dressed  lightly,  the 

limb  is  incased  in  a  silicate-of-soda  splint,  and 
the  patient  is  ordered  to  walk  about  on  crutches, 
whether  osseous  union  be  present  or  not.  Gradu- 
ally the  use  of  crutches  is  dispensed  with,  and 
the  patients  generally  learn  to  walk  very  well  on 

__      an  elevated  sole,   compensating 

the  shortening. 

Of  twelve  cases  of  total  ex- 
section  done  by  the  author  for 
tuberculosis,  eleven  recovered. 
One  died  of  meningeal  tubercu- 
losis. 

Case  I.— Fred.  Fuchs,  aged  sev- 
en. Osseal  relapsing  tuberculosis 
after  arthrectomy,  done  by  Dr.  F. 
Lange  in  June,  1885.  March  4i 
1884. — Total  exsection,  done  at  the 
German  Hospital,  reveals  two  periarticular  abscesses  and  five  cheesy  foci  in  tibia  and 
femur.     Suppuration  of  wound.     March  10th. — Incision  of  abscess  on  outer  aspect  of 


-Dec;p  support  of  cxsc^e.tfd  Ivnee-joint  by 
.short  lateral  Ixiard  s])lint.s. 


TREATMENT  OF  TUBERCULOSIS. 


291 


Fig.  228. — External  long  lateral  pasteboard  splints  after  exsec- 
tion  of  knee-joint,  applied  over  complete  dressing. 


knee.      April   ^.'?<^.— Separation  of  epiphysis  of  tibia.      Separated  epiphysis  firmly 
united  to  femur.     In  April  .symptoms  of  meningeal  tuberculosis  developed,  to  which 

patient  succumbed  May  31st. 

In  one  of  the  remaining  eleven  cases  ampu- 
tation of  the  thigh  became  necessary  on  account 
of  suppuration. 

Case  II. — H.  Desmond,  professional  athlete,  aged 
tiiirty.  Extensive  destruction  of  right  knee-joint  by 
tuberculosis,  complicated  with  pyogenic 
infection.  The  knee,  leg,  and  thigh  con- 
tain a  large  number  of  abscesses.  Pro- 
fuse secretion  from  seven 
fistulse.  The  case  was  not 
suitable  for  exsection,  and 
amputation  was  advised. 
But,  at  the  patient's  ur- 
gent request  to  make  an 
attempt  to  save  Ms  limb, 
February  14,  1884,  total 
exsection  vras  done  at  the 
German  Hospital.  As  sup- 
puration was  expected,  the 
extremity  was  fixed  to  an  interrupted  dorsal  suspension  splint  made  of  hoop-iron  and 
plaster  bandages.  Profuse  suppuration  followed  with  evident  prostration,  and,  April 
19th,  amputation  of  the  thigh  was  performed.  The  wound  healed  by  granulation,  and 
in  June  patient  was  discharged  cured. 

Ten  cases  were  cured  with  preservation  of  the  limb.  In  nine  of  these, 
firm  bony  anchylosis  was  secured.  One  case  terminated  in  the  formation 
of  ligamentous  union. 

Case  I. — Niclas  Gies,  carpenter,  aged  fifty-four.  Synovial  tuberculosis  with  high 
temperatures  and  emaciation  following  a  slight  traumatism.  Contraction  of  knee  at 
an  acute  angle,  with  constant  violent  pain.  February  19,  1886. — At  the  German  Hos- 
pital, puncture  yielded  a  small  quantity  of  turbid  bloody  serum.  In  ansesthesia  the 
limb  was  straightened,  and  the  joint  was  incised,  irrigated,  and  drained.  The  fever  at 
once  disappeared,  but  flocculent  pus  commenced  to  exude  from  the  tubes,  confirming 
the  assumption  of  tuberculosis.  In  view  of  the  patient's  age,  his  wretched  general 
condition,  due  partly  to  disease  and  to  chronic  alcoholism,  amputation  was  thought  to 
be  advisable.  The  plan  of  operation  was  changed  at  the  operating-table,  and  total 
exsection  of  the  knee-joint  was  done.  Hseraorrhagic  synovitis  and  a  large  cheesy 
deposit  in  the  bursa  of  the  quadriceps  were  found.  Five  nails  were  employed,  with 
an  aseptic  dressing  and  pasteboard  splints.  Temporary  compression  by  Martin's  elas- 
tic bandage  was  applied  to  control  secondary  oozing.  Esmarch's  constrictor  was 
removed  after  the  completion  of  the  bandage.  A  feverless  course  of  healing  fol- 
lowed. Change  of  dressings  was  done  on  the  twenty-second  day.  Four  nails  were 
found  loose,  and  were  withdrawn.  May  8th. — Scraping  of  drainage-tracks  and 
removal  of  fifth  nail.  Ligamentous  union  was  found  and  a  plaster  splint  applied. 
June  12th. — The  sinuses  were  healed,  and  the  patient  was  walking  without  the  aid 
of  stick  or  crutches  in  a  light  silicate-of-soda  splint,  though  union  of  the  bones  was 
not  perfect. 


292  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

The  other  nine  cases  were  in  brief  as  follows  : 

Case  II. — Willie  Bohn,  aged  three  and  a  half.  Osseal  tuberculosis  with  fistute. 
February  2^  1879. — Total  exseetiou,     April  2d. — Patient  discharged  cured. 

Case  III. — Charles  Harris,  aged  twelve.  Osseal  tuberculosis  with  tistuli© ;  con- 
tracture and  subluxation  backward.  June  13,  1884. — Total  exsection  at  the  German 
Hospital.  Hahn's  incision;  two  nails;  plaster- of-Paris  splint.  Some  fever  and  deep- 
seated  oedema  of  the  region  ot  the  knee  followed.  Sawed  surfaces  and  flesh-wound 
united  by  primary  union.  Tlie  nails  being  withdrawn  on  the  twelfth  day,  some  pus 
exuded  from  their  tracks,  showing  that  the  nails  had  apparently  not  been  well  disin- 
fected. Several  revisions  were  required  on  account  of  unhealthy  granulations  in  the 
drainage-holes.  February  ^,  iSS^- — Patient  discharged,  with  firm  anchylosis  and  no 
fistula. 

Case  IV. — Sussel  Baerenknopf,  aged  nine.  Osseal  tuberculosis ;  several  fistulas  ; 
subluxation.  August  26, 1885. — Total  exsection  at  Mount  Sinai  Hospital.  Nails;  plaster 
splint.  September  25th, — Change  of  dressing.  Drainage-tubes  and  nails  were  with- 
drawn; firm  anchylosis.     October  10th. — Patient  discharged  cured. 

Case  V. — Leonard  Peters,  waiter,  aged  nineteen.  Synovial  tuberculosis;  no  fis- 
tula. August  27,  1885. — Total  exsection  at  the  German  Hospital.  September  27th. — 
Plaster  splint,  dressings,  drainage-tubes,  and  nails  removed.  October  9th. — Sinuses 
healed.     October  19th. — Discharged  cured  with  firm  anchylosis. 

Case  VI. — Bertha  Deutsch,  aged  twelve.  Synovial  tuberculosis  of  five  weeks' 
standing.  Continuous  high  fever  with  rapid  emaciation.  Probatory  puncture  yielded 
scanty  bloody  serum.  January  21,  1886. — Total  exsection  at  Mount  Sinai  Hospital. 
The  capsule  was  found  studded  with  innumerable  miliary  tubei'cles.  The  fever  disap- 
peared immediately  after  the  operation.  February  20th. — Plaster  splint  removed ; 
wound  healed  by  first  intention.  March  10th. — Patient  discharged  cured,  with  firm 
anchylosis. 

Case  VII. — Lizzie  Boettger,  aged  twenty.  Osseal  tuberculosis  of  eighteen  years' 
standing;  rectangular  contraction  with  subluxation  backward.  No  fistula.  February 
12,  1886. — Total  exsection  at  German  Hospital.  March  10th. — Change  of  dressings ; 
primary  union;  three  nails  and  drainage-tubes  were  removed.  April  Jfih. — Patient 
complained  of  a  good  deal  of  pain  in  walking.  A  hard  body  could  be  felt  under  the 
skin  on  the  outer  aspect  of  the  tibia.  An  incision  exposed  the  head  of  the  fourth  nail, 
which  had  not  been  found  at  the  first  change  of  dressings.  It  was  withdrawn  with 
some  force,  a  little  blood  exuding  from  its  track.  May  9th. — Patient  was  discharged 
cured. 

Case  VIII. — Anna  Sauer,  aged  twenty-two.  Synovial  tuberculosis  with  osseal 
ulceration  of  articular  surfaces  of  both  femur  and  tibia.  No  fistula.  May  10,  1886. — 
Total  exsection  at  the  German  Hospital.  June  12th. — First  change  of  dressings ; 
primary  union  of  soft  parts ;  delayed  union  of  the  bones.  August  1st. — Discharged 
cured,  with  firm  anchylosis. 

Case  IX. — Katie  Walter,  aged  eighteen.  Synovial  tuberculosis  with  caseous  de- 
posits in  several  recesses  of  the  capsule,  notably  around  and  beliind  the  crucial  liga- 
ments. Caries  of  articular  surfaces.  No  fistula.  May  18,  1886. — Total  exsection  at 
the  German  Hospital.  Slight  fever  following  the  operation,  the  dressings  were  re- 
moved May  2Gth.  Marginal  slough  of  the  upper  edge  of  the  skin-woiind.  June  17th. 
— Nails  were  removed  ;  firm  anchylosis.     July  26th. — Patient  discharged  cured. 

Case  X. — Emma  Friedmann,  aged  twenty-seven.  Synovial  tuberculosis  with  caries 
of  articular  surfaces.  No  fistula.  April  18,  1887. — Total  exsection.  April  22d. — 
Considerable  secondary  oozing  necessitated  a  change  of  external  dressings  and  plaster 
splint.     Feverless   course.     May  23d. — Change  of   dressings;    primary  union;    firm 


TREATMENT  OF  TUBERCULOSIS. 


293 


anchylosis.  Tubes  and  three  nails  were  removed ;  a  fourth  nail  could  not  be  found, 
but  was  removed  by  incision  on  June  2d.  Patient  was  discharged  cured,  with  firm 
anchylosis,  July  1st. 

Note. — To  prevent  the  disagreeable  necessity  of 
cutting  down  for  searching  out  a  nail  buried  in  the 
tissues,  Dr.  F.  Lange's  suggestion  of  fastening  a  silk 
ligature  to  the  head  of  each  nail  before  driving  it  in, 
seems  to  be  very  appropriate. 


Fic 


229. — Arrangement  of  patient  for 
Mikulicz's  operation. 


/.  Ankle  and  Foot. — Tuberculous 
aifectious  of  the  ankle-Joint,  or  of  the 
Joints  formed  by  the  tarsal  and  metatar- 
sal bones,  require,  in  case  of  the  presence 
of  one  or  more  sinuses,  exsection  of  the 
diseased  parts.  The  long-continued  dis- 
charges and  lack  of  active  exercise  are 
,jj      very  apt  to  reduce  the 

general  condition  of  the  patient  to  serious  anaemia  and 
marasm,  and,  the  disease  extending  to  most  of  the  com- 
plicated structures  of  the  foot,  may  finally  require  am- 
putation. 

Early  operations,  especially  in  chil- 
dren, yield  good  functional  results,  as 
the  extent  of  tlie  removal  can  be  lim- 
■ '    1  '     the  parts  actually  involved. 

Exsections 
of  the  ankle  or 
of  other  Joints 
of  the  foot  are 
not  followed 
by  good  results 
in  grown  sub- 
jects, on  ac- 
count of  the  technical  difficulty  of  a  complete  removal 
of  the  synovial  membrane.  Relapse  of  the  tubercu- 
lar process  often  suiDcrvenes,  making  amputation  a 
necessity. 

In  tuberculosis  of  the  calcaneum  or  the  astragalo- 
calcaneal  Joint,  MihuUcz's  osteoplastic  exsection  of  the 
tarsus  deserves  employment.      The  lower  ends  of  the 
tibia  and  fibula  are  sawed  off  as  in  Syme's  amputation, 
and  the  articular  surfaces  of  the  cuboid  and  scaphoid 
bones  are  also  sawed  off,  so  as  to  fit  the  section  of  the 
tibia  and  fibula.     (Fig.  230.)     Nutrition  of  the  ante- 
rior part  of  the  foot  is  maintained  by  the  dorsalis  pedis  artery,  and  the 
patient  soon  learns  to  walk  on  the  balls  of  the  toes,  as  in  pes  equinus. 
(Fig.  231.) 
89 


230. — Diagram  illustrating  the  plan  of 
Mikulicz's  operation.     (Esmarch.) 


Fig.  231.— Shape  of  foot 
after  Mikulicz's  oper- 
ation.    (Esmarch.) 


294  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Case. — Hermann  Mehle,  barber,  aged  thirty-four.  Synovial  tuberculosis  of  the 
astragalo- calcaneal  joint,  with  several  fistulse  situated  to  the  right  and  left  of  the 
tendo  Achillis.  August  SO,  1885. — Osteoplastic  exsection  of  tarsus  at  the  German 
Hospital.  Primary  union  of  the  deep  parts  of  the  wound  and  of  the  bones.  Mar- 
ginal sloughing  of  limited  extent  of  the  upper  edge  of  the  wound  delayed  the  cure 
somewhat.     October  10th. — Patient  was  discharged  cured. 

Note. — This  operation  was  employed  by  the  author  successfully  in  two  more  cases.  In  one, 
an  epithelioma  of  the  calcaneal  region ;  in  the  other,  extensive  chronic  ulceration,  due  to  frost- 
bite of  the  heel,  was  the  indication  to  its  performance. 

The  preparation  of  the  foot  to  be  operated  on  is  of  very  great  importance, 
and  thorough  removal  of  effete  epidermis  and  dirt  is  a  necessary  condi- 
tion of  asepticism  (see  page  61).  In  exsection  of  the  ankle,  the  bilateral 
incision  gives  very  good  access  to  the  ankle-joint,  though  excision  of  the 
capsule  will  he  found,  at  best,  difficult  to  accomplish. 

It  being  desirable  to  produce  a  movable  joint,  subperiosteal  dissection 
is  to  be  aimed  at,  as  in  exsection  of  the  elbow.  As  soon  as  the  sinuses  are 
healed,  active  use  of  the  foot  on  crutches,  aided  by  a  shoe  and  brace,  or  a 
silicate-of-soda  splint,  should  be  encouraged.  The  tendency  to  posterior  or 
lateral  deviation  of  the  foot  will  be  best  met  by  the  long-continued  use  of  a 
supporting  apparatus  of  one  kind  or  another. 

Case  T. — Oaecilia  Raab,  aged  twenty-two.  Synovial  tuberculosis  of  ankle-joint 
with  several  sinuses.  JSfovernber  9,  1882. — Exsection  of  ankle-joint  at  the  German 
Hospital.  Healing  of  the  wound  progressed  favorably,  when,  November  30th,  the 
patient  contracted  acute  lobar  pneumonia,  in  consequence  of  which  she  died  Decem- 
ber 2,  1882. 

Case  II. — George  Eitt,  aged  six.  Tuberculosis  of  ankle-joint  caused  by  a  cheesy 
focus  in  the  astragalus.  January  11,  1888. — Partial  exsection  of  ankle-joint,  part  of 
the  astragalus  and  the  malleoli  being  removed.  March,  13th. — Scraping  of  the  sinuses 
on  account  of  relapsing  tuberculosis.  Sinuses  persisted  until  the  summer  of  1884,  when 
Dr.  F.  Lange,  then  on  duty  at  the  German  Hospital,  performed  total  exsection,  which 
resulted  in  a  cure  of  the  tuberculosis,  but  with  pseudarthrosis.  July  SO,  1885. — The 
author  exsected  the  ligamentous  mass  interposed  between  the  lower  aspect  of  the  tibia 
and  fibula  and  the  calcaneum,  and  fixed  the  latter  to  the  tibia  by  a  steel  nail  driven 
through  from  the  planta  pedis.  Primary  adhesion  followed,  with  the  formation  of  a 
slightly  movable  union  of  the  tibia  and  calcaneum.  /September  5th. — The  boy  was  dis- 
charged cured.     In  January,  1886,  the  brace  worn  until  then  was  dispensed  with. 

Case  HI. — Henry  Holzfaller,  aged  four.  Osseal  tuberculosis  of  ankle-joint.  March 
20,  1883. — Total  exsection  at  the  German  Hospital.  May  25th. — Patient  discharged 
cured,  with  serviceable  joint. 

Case  IV. — Frida  Schmoltz,  aged  three  and  a  half.  Osseal  tuberculosis  of  ankle- 
joint  with  fistula.  September  19,  1883. — Removal  of  external  malleolus  and  part  of 
astragalus,  which  contained  a  caseous  deposit.  October  15th. — Wound  completely 
healed.  Plaster-of-Paris  splint  applied.  October  31st. — Silicate-of-soda  splint  applied, 
and  patient  directed  to  use  the  foot.  August  Jf,,  1885. — Normal  position  of  foot;  func- 
tion perfectly  re-established. 

Case  V. — I.  S.,  aged  eight.  Osseal  tuberculosis  of  ankle-joint  with  three  sinuses. 
September  26,  1883. — Partial  exsection  of  ankle-joint;  astragalus  and  inner  malleolus 
were  removed.  November  15th. — Patient  discharged  cured,  with  improving  function 
and  normal  position  of  the  foot. 


TREATMENT  OF  TUBERCULOSIS.  295 

Case  VI.— Jacob  Deibel,  farmer,  aged  twenty-three.  Synovial  tuberculosis  of 
ankle  and  of  astragalo-calcaneal  joints.  March  12,  i5,*?6.— Removal  of  both  malleoli 
and  of  entire  astragalus  at  the  German  Hospital.  April  20tJi.—? oWeni  discharged 
cured,  with  fair  function  of  the  foot,  walking  with  the  aid  of  a  stick. 

Case  VII.— Abraham  Moses  Goldenberg,  aged  four.  Osseal  tuberculosis  of  ankle- 
joint  with  sinuses.  November  8,  1S86.— Total  exsection.  Several  relapses  required 
repeated  scraping  with  the  sharp  spoon.  June  3,  1887.— The  patient  was  discharged 
cured. 


PART    IV. 

GONORRHCE  A : 

ITS    ANTISEPTIC    TEEATMEI^T. 


CHAPTER  IX. 


NATURAL  HISTORY  AND    TREATMENT  OF  GONORRHCEA. 
I.     ETIOLOGY    OF    GONORRHCEA.      GONOCOCOUS. 


Fig.  232. 
Pure    culture    of 
gonocoocus (700 
diameters). 
(From  Bumm.) 


In  examiniug  the  purulent  secretion  produced  by  a  virulent  case  of  ure- 
thral gonorrhoea,  the  observer  will  detect  with  the  microscope  a  number  of 
dark,  round  objects  resembling  grains  of  fine  gunpowder,  that  are  vividly 
oscillating,  and  can  be  clearly  distinguished  from  the  adja- 
cent pus-corpuscles.     The  use  of  a  stronger  lens  will  reveal  i'.'S^,^ 
the  fact  that  each  individual  coccus  is  divided  in  two  un-            ^'tTi'* 
equal  halves.     If  staining  is  employed,  the  body  of  the  coc- 
cus will  appear  colored,  and  the  dividing-line  will  become 
very  conspicuous  in  the  shape  of  a  light,  colorless  streak. 
(Fig.  233.) 

Frequently  an  indication  of  incipient  secondary  division  of  each  half  of 
the  coccus  can  be  seen.  Thus  four  cocci  will  be  united  to  a  seemingly  single 
body,  which  can  be  aptly  compared  with  four  coherent  biscuits,  divided  into 

equal   quarters   by  two  cross -shaped 

grooves. 

The  favorite  location  of  the  gono- 

cocci  found  in  the  urethral  secretions 

is  loitliin   the  pus- corpuscles.      This 

peculiarity  belongs  exclusively  to  the 

coccus  of  gonorrhoea  detected  by  Neis- 
ser  in  1879,  and  represents  its  most  important  charac- 
teristic.    (Fig.  234.) 

Oonococci  are  to  he  found  in  the  secretion  of  every 
case  of  gonorrhoea,  provided  that  no  germicidal  injec- 
tions were  used. 

Infection  of  the  urethra  with  pus  containing  gono- 
cocci  ahv ays  produces  gonorrhoea,  and  secretions  that  do 
not  contain  gonococci  are  invariably  non-infectious  if 
brought  upon  the  urethral  mucous  membrane. 

Gronococci  have  a  peculiarly  invasive  faculty,  by  which  they  penetrate 
first  the  superficial  layers  of  the  epithelial  membrane,  and  gradually  by 
further  proliferation  the  submucous  layer.     (Fig.  236).     The  route  of  their 


|rffi     ^   (^      «MC        W 

Fig.  233. 
Development    and 
fission   of  gono- 
coccus.       (From 
Bumm.) 


Fig 


cell  studded  with 
gonococci ;  pus  cell, 
its  protoplasm  filled 
with  gonococci ;  an- 
other pus  cell  gorged 
with  gonococci ;  a 
group  of  free  cocci 
alongside  of  a  nor- 
mal pus  -  cell  (700 
diameters).  (From 
Bumm.) 


300 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


^^.  - 


w\; 


yo]) 


Fig.  235. — Vertical  section  through  mu- 
cous membrane,  showing  first  coloni- 
zation of  gonococci  (700  diameters). 
(From  Bumm.) 


inroads  is  along  the  intercellular  substance.  An  intense  hypergemia  of  the 
capillaries  and  other  blood-vessels  adjoining  the  seat  of  the  primary  infec- 
tion leads  to  a  massive  emigration  of  white  blood-corpuscles  into  the  affected 
epithelium.    This  and  the  growth  of  the  gonococcal  colonies  lead  to  a  rapid 

disintegration  of  the  epithelium,  which  is 
washed  away  by  the  lymph-serum  in  the 
shape  of  single  cells  or  in  coherent  epi- 
thelial flakes.  Loss  of  the  epithelial  in- 
vestment is  often  followed  by  the  exuda- 
tion of  a  croupous  membrane,  beneath 
which  clumps  of  gonococci  are  to  be  seen 
in  process  of  active  proliferation.  Gono- 
cocci can  be  found  occupying  at  this 
stage  the  interstices  of  the  subepithelial  tissues,  their  columns  extend- 
ing inward  along  the  lymphatics,  whence,  according  to  various  authors 
(Kammerer),  they  may  be  transported  to  the  endocardium,  the  joints,  and 
the  synovial  sheaths  of  tendons. 

With  the  deeper  invasion  by  the  gonococci  goes  'pari  passu  the  dense 
infiltration  of  the  in- 
fected tissues  with 
leucocytes,  the  ex- 
tent of  which  serves 
as  a  gauge  of  the  in- 
tensity of  the  infec- 
tious process. 

At  the  acme  of 
the  process,  general- 
ly reached  about  the 
end  of  the  second  or  third  week,  a  regeneration  of  the  lost  epithelial  layer 
commences.  Comj^lete  restitution  of  the  epithelium  signalizes  the  termina- 
tion of  the  malady,  which,  however,  is  attained  only  in  favorable  cases  under 
favorable  conditions.  Generally  primarily  unaffected  parts  of  the  mucous 
membrane  become  involved  by  spontaneous  extension  of  the  infective  pro- 
cess, or  by  the  improper  use 
«  M!fl,  *~  ^"^^^'''  of  instruments  ;   or  portions 

_         ^'^  ' '  ,  _  which    have    recovered    suc- 

-7i0?f''<^  1     "^  ~^-'  cumb  anew  to  gonococcal  de- 

struction. 

The  regeneration  of  the 
epithelium  is  always  accom- 
panied by  hyperplasia,  which 
somewhat  resembles  by  its 
tubular  formations  epitheliomatous  mucous  membrane  (Bumm).  These  foci 
of  epithelial  hyperplasia  are  often  coincident  with  the  seat  of  the  most  intense 
primary  affection.  They  also  coi*respond  with  those  parts  of  the  submucous 
layer  at  which  the  most  intense  inflammatory  infiltration  was  present. 


Fig.  236.- 


-Invasion  of  epithelium  by  gonococci  (700  diameters). 
(From  Bumm.) 


^"-^'^ 


^1  s,®^#)«  «» 


Fig.  237.- 


-Proliteration  of  gonococci  in  the  epithelium 
(700  diameters).     (From  Bumm.) 


TREATMENT  OF  GONORRHCEA.  301 

As  regeneration  progresses,  the  lijperplasia  of  the  mucous  membrane 
and  the  infiltration  of  the  submucous  connective  tissue  disappear  by  absorp- 
tion. In  some  cases,  however,  cicatricial  transformation  of  the  neiv-formed 
connective  tissue  of  the  suhmucous  layer  taTces  place  instead  of  absorption, 
and  organic  stricture  develops. 

The  transient  hyperplastic  conditions  existing  immediately  after  the 
termination  of  the  gonorrhceal  process,  and  which  generally  give  rise  to  a 
scanty  secretion  called  gleet,  are  mistahenly  called  strictures  hy  various 
authors. 

In  contradistinction  to  stricture,  which  is  a  permanent  condition,  they 
must  be  declared  to  be  transient  stenoses  of  the  urethral  caliber,  which  in 
most  cases  do  disappear  without  or  with  the  methodical  introduction  of  a 
full-sized  bougie  or  sound.  The  salutary  effect  of  dilatation  upon  these 
coarctations  of  the  epithelial  and  submucous  layers  is  explained  by  the 
hastening  of  the  absorption  of  the  cellular  infiltration  by  pressure. 

It  is  true  that,  if  neglected,  some  of  these  coarctations  will  not  be  ab- 
sorbed, but  will  become  veritable  cicatricial  strictures.  Nevertheless,  it  is 
an  error  to  declare  each  and  every  narrowing  of  the  urethral  calHer  observed 
shortly  after  a  gonorrhceal  attach  a  "stricture  of  ivide  caliber."  The  term 
of  ''incipient -stricture"  is  less  objectionable,  though  often  incorrect,  as 
many  of  these  "strictures"  disappear  spontaneously. 

Note. — The  presence  of  various  micro-organisms,  aside  from  the  gonococeus,  in  recent  and 
chronic  urethral  discharges,  seems  to  point  to  the  fact  that  most  cases  of  urethritis  represent  a 
mixed  form  of  bacterial  infection.  There  is  no  doubt  that  the  mocula.tion  oi  pt/offenic  mic7'obes 
into  a  gonorrhoeally  affected  mucous  membrane  foi'ms  an  important  element  determining  the 
intensity  and  perniciousness  of  some  very  bad  cases.  This  assumption  is  also  more  in  accord- 
ance with  the  theory  of  the  development  of  metastases,  notably  of  gonorrhceal  rheumatism. 
Bumm  is  very  reserved  in  regard  to  the  acceptance  of  Kammerer's  investigations,  who  found 
gonococci  in  recent  effusions  produced  during  an  attack  of  gonorrhceal  rheumatism.  On  the 
other  hand,  we  know  that  rheumatic  attacks  are  occasionally  provoked  by  an  instrumental 
examination  of  the  urethra  of  a  patient  afflicted  with  "  simple  "  or  "catarrhal "  or  "traumatic" 
urethritis,  in  which  the  absence  of  gonococci  is  indisputable.  Finally,  the  frequent  presence  of 
simple  pyogenic  organisms  in  rheumatic  effusions  is  generally  accepted.  It  seems,  then,  that 
pus-generating  organisms  play  an  important  part  in  cases  of  gonorrhceic  and  non  gonorrhoeic 
urethritis,  and  that  the  metastatic  processes  complicating  ui-ethral  inflammations  are  mostly 
chargeable  to  their  and  not  to  the  presence  of  gonococci.  Hence  the  name  "  urethral  rheuma- 
tism "  would  be  preferable  to  "  gonorrhceal  rheumatism.'' 

II.     TREATMENT    OF   GONORRHCEA. 

1.  Acute  Gonorrhoea.  Clap. — For  practical  reasons  it  will  be  found 
most  convenient  to  divide  the  male  urethra  into  two  easily  distinguished 
parts. 

The  first  part  comprises  the  anterior  poi^tionoi  the  urethra,  extending 
from  the  meatus  to  the  ''cut-off  muscle,"  or  compressor  urethrce,  which  is 
situated  in  the  membranous  portion.  All  secretions  originating  in  this 
anterior  portion  of  the  urethra  will  readily  escape  by  the  meatus  into  the 
linen  of  the  patient. 
40 


302  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

Tlte  second  or  dee}}  portion  of  the  urethra  consists  of  a  fraction  of  the 
membranous  part,  together  with  the  prostatic  portion — in  short,  of  all  that 
is  situated  behind  the  "cut-off  muscle." 

This  posterior  portion  of  the  urethra  is  correctly  called  the  nech  of  the 
bladder,  as  it  forms  one  cavity  with  the  bladder  whenever  this  becomes 
distended  with  urine.  The  internal  sphincter  alone,  unable  to  resist  long, 
yields  readily  to  the  pressure  of  the  urine.  The  voluntary  contraction  of 
the  compressor  urethrae  becomes,  then,  the  only  barrier  to  the  escape  of  the 
urine,  and  water  is  voided  immediately  after  the  relaxation  of  this  muscle. 

Discharges  secreted  in  the  posterior  part  of  the  urethra  can  not  escape 
outward  past  the  compressor  muscle,  and  do  not  appear  at  the  meatus  in 
the  shape  of  an  external  discharge,  as  those  of  the  anterior  urethra.  They 
accumulate  in  the  neck  of  the  bladder,  and  are  voided  only  with  the  urine, 
which  is  rendered  somewhat  turbid  by  this  admixture. 

A  very  useful  practical  test  for  determining  the  seat  of  urethral  inflam- 
mation is  that  suggested  by  Ultzmann. 

The  patient  is  made  to  pass  his  water  consecutively  into  two  tumblers, 
so  that  the  amount  voided  should  be  about  evenly  distributed  in  the  two 
vessels.  Whenever  the  anterior  urethra  alone  is  the  seat  of  inflammatio?i, 
only  the  first  half  of  the  urine  will  be  turbid,  or  at  least  will  be  found  con- 
taining flakes  and  threads  ;  the  second  portion  will  appear  perfectly  clear. 

In  cases  of  deep-seated  urethritis — that  is,  when  the  neck  of  the  bladder 
is  affected — the  first  tumbler  luill  receive  flaky  and  turbid  urine,  and  the 
water  held  by  the  second  glass  will  appear  also  turbid,  but  somewhat  less  so 
than  the  first  portion. 

A-W  additional  and  most  important  symptom  of  the  affection  of  the  neck 
of  the  bladder  \'&  frequent  micturition,  in  acute  cases  accompanied  by  severe 
spasm  and  the  escape  of  a  small  quantity  of  blood  at  the  end  of  the  act. 
Simultaneously  with  the  severe  contraction  of  the  vesical  muscles,  anal 
tenesmus  is  observed. 

In  every  case  of  recent  gonorrhoea  the  infectious  process  is  confined  to 
the  anterior  urethra,  and  first  to  its  foremost  portion  alone.  It  extends 
from  the  meatus  backward  to  the  compressor  urethrae,  where  it  generally 
stops.  In  exceptional  cases  only  does  it  penetrate  to  the  deep  urethra,  as 
the  "cut-off  muscle"  seems  to  serve  as  an  effective  barrier  to  its  extension 
backward. 

Note. — Forcible  urethral  injections  made  from  a  syringe  containing  too  large  a  quantity  of 
fluid,  or  the  premature  introduction  of  a  sound,  are  frequent  causes  of  the  infection  of  the  neck 
of  the  bladder. 

The  seat  of  the  most  intense  inflammation  of  the  urethra  is  in  its  natu- 
rally widest  parts — that  is,  in  the  fossa  navicularis  and  the  sinus  bulbi.  Here 
we  find  located  the  majority  of  all  strictures. 

a.  Anterior  Gonorrhceal  Urethritis. — The  treatment  of  anterior 
gonorrhoeal  urethritis  should  be  very  discreet  in  the  first  invasive  stage  of 
the  disease.  It  should  consist  of  rest  and  appropriate  general  sedative  man- 
agement.   Locally,  cold  applications  will  be  found  very  grateful  and  effective. 


TREATMENT  OF  GONORRHOEA.  303 

As  soon  as  the  turbulent  first  onset  has  abated,  local  treatment  by  dis- 
infectants should  commence.  Since  the  oedematous  swelling  of  the  parts 
is  still  prom.inent,  introduction  of  any  instrument  for  the  purpose  of  irri- 
gation will  have  to  be  done  with  some  force.  It  will  cause  abrasions  of  the 
tumid  ei3ithelium,  and  thus  will  open  new  portals  to  gonococcal  and  pyo- 
genic invasion.     Hence  irrigation  at  this  period  is  to  be  condemned. 

Urethral  injections,  on  the  other  hand,  done  with  a  joroperly  shaped 
syringe  of  moderate  cajiacity,  are  very  useful.  Sigmund's  syringe,  hav- 
ing a  blunt  conical  nozzle,  is  an  appropriate  instrument.  It  holds  three 
eighths  of  an  ounce 
of  fluid,  which  quan- 
tity is  sufficient. 
(Fig.  238.) 

The    strength    of  Fig.  238.— Sigmund's  urethral  syringe. 

the  solutions  em- 
ployed should  also  be  determined  by  the  intensity  of  the  local  symptoms. 
Strong  solutions  will  cause  intense  smarting,  and  on  that  account  the  injec- 
tions will  not  be  made  frequently  enough  by  the  patient.  In  very  sensitive 
cases  an  entirely  unirritant  tepid  solution  of  salt  water  (6:1,000,  or  a  tea- 
spoonful  to  a  quart)  can  be  employed  with  much  benefit.  As  the  symptoms 
abate,  sulphocarbolate  of  zinc  (fifteen  grains  to  six  ounces),  or  permanganate 
of  potash  (one  grain  to  six  ounces),  can  be  substituted  for  the  saline  solution. 

The  main  object  of  these  first  injections  is  the  cleansing  of  the  urethra  ; 
hence  the  injections  must  he  made  frequently ,  at  least  six  times  in  a  day,  or 
oftener.  Each  injection  should  be  preceded  by  urination,  and  should  be 
a  double  one — the  first  syringeful  to  wash  out  the  pus  ;  the  second  syringe- 
ful  to  act  upon  the  mucous  membrane.  This  second  injection  should  be 
retained  in  the  urethra  for  two  minutes.  The  strength  of  the  injections 
should  be  increased  ^an  passu  with  the  abatement  in  the  acuity  of  the  local 
symptoms,  but  the  solutions  should  never  be  made  corrosive. 

Every  patient  should  receive  practical  instruction  from  the  physician 
regarding  the  proper  manner  of  injecting. 

Note. — The  author  saw  a  case  of  chronic  gonorrhoea  that  had  successively  passed  through 
the  hands  of  three  colleagues,  none  of  whom  convinced  himself  whether  the  patient  was  making 
the  injections  properly  or  not.  Phimosis  was  present,  and  the  patient  was  in  the  belief  that 
the  injections  had  to  be  made  under  the  prepuce.  No  wonder  his  clap  had  remained  uninflu- 
enced by  this  treatment. 

In  the  later  stages  of  acute  gonorrhoea  irrigation  of  the  anterior  urethra 
will  be  found  a  very  satisfactory  and  effective  mode  of  treatment.  It  should 
be  done  by  the  physician  himself  at  least  once  daily,  or  as  often  as  possible, 
in  the  following  manner  : 

A  pint  bowl  is  filled  with  tepid  water.  To  this  is  added  enough  con- 
centrated solution  of  permanganate  of  potash  to  color  the  water  to  the  hue 
of  light  claret.  A  straight  or  slightly  beaked  female  catheter  of  metal  (Fig. 
239),  five  inches  in  length  (No.  8  English  caliber),  is  lubricated  with  glyc- 
erin, and  is  introduced  as  far  as  the  compressor-urethrse  muscle.     When- 


304:  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

ever  the  beak  of  the  instrument  comes  in  contact  with  the  muscle  this  will 
contract,  and  will  resist  further  introduction.  The  patient  stands  in  front 
of  the  sitting  physician,  and  is  made  to  hold  a  pus-basin  or  tin  pan  under 

his  scrotum  and  penis.  The 
physician  fills  with  the  solution 
a  hand-syringe  holding  four  or 
five  ounces,  and  iniects  the  fluid 

Fig.  1^39. — Short  metallic  catheter  for  irrigation  of  ^      n  ,^     ,         •    ,       ,^ 

anterior  urethra.  through  the  catheter  mto  the 

urethra,  whence  it  will  readily 
escape  by  the  meatus  into  the  pus-basin.  This  is  repeated  until  the  solu- 
tion is  exhausted.     Irrigation  should  be  preceded  by  micturition. 

With  proper  diet  and  regime,  ordinary  cases  of  gonorrhoea  will  be  cured 
by  this  treatment  in  from  three  to  six  weeks. 

Note. — To  prevent  soiling  of  the  patient's  linen  by  profuse  urethral  discharges,  the  follow- 
ing simple  arrangement  will  be  found  effective  and  convenient.  A  child's  sock  is  fastened  with 
a  safety-pin  to  the  interior  of  the  skirt  of  the  patient's  undershirt.  In  the  toe  of  the  sock  is 
thrust  a  small  ball  of  cotton,  which  is  then  drawn  over  the  penis,  and  is  held  there  by  the  sock. 
Whenever  occasion  permits,  the  soiled  cotton  is  replaced  by  clean  material,  and  thus  no  tell- 
tale blotches  will  be  made  on  shirt  and  drawers. 

b.  Deep-seated  Goistorehceal  Urethritis. — Spontaneous  extension 
of  gonorrhoeal  infection  beyond  the  cut-off  muscle  to  the  posterior  part  of 
the  urethra  is  a  comparatively  rare  occurrence.  More  frequently  infection 
is  carried  to  the  deep  urethra  by  too  large  injections  or  the  premature  inser- 
tion of  sounds.  As  long  as  in  a  case  of  anterior  gonorrhoea  the  discharges 
are  profuse  and  creamy,  and  the  mouth  of  the  urethra  mdematous  and  red, 
no  sound  should  ever  he  passed. 

Infection  of  the  deep  urethra  invariably  provokes  an  unmistakable  com- 
plex of  symptoms — namely,  frequent  urination,  which  is  followed  at  its 
termination  by  a  violent  s^Dasmodic  pain  and  the  escape  of  some  bloody 
urine  or  a  few  drops  of  pure  blood. 

Ordinary  injections,  or  even  irrigations  of  the  urethra  as  above  described, 
are  utterly  unable  to  reach  and  to  influence  the  course  of  deep-seated  gon- 
orrhoea. To  cleanse  and  disinfect  the  diseased  part,  an  efficient  germicidal 
solution  must  be  brought  exactly  in  contact  with  the  morbid  mucous  mem- 
brane of  the  posterior  urethra.  If  we  inject  a  solution  into  the  bladder,  its 
chemical  properties  will  be  at  once  destroyed  by  the  admixture  of  urine, 
hence  means  must  be  found  by  which  we  can  make  the  unchanged  solution 
come  in  contact  with  the  seat  of  the  disease.  For  this  purpose  Ultzmann's 
method  of  irrigating  the  necTc  of  the  Madder  will  be  found  very  effective. 

As  soon  as  the  most  acute  invasive  stage  of  the  affection  shall  have  be- 
come mitigated  by  rest,  sedatives,  balsamics,  and  proper  diet — that  is,  in  about 
the  third  or  fourth  week — a  quart  of  a  mild,  tepid  solution  of  permanganate 
of  potash  (1  :  5,000)  is  prepared.  A  not  too  small-sized  soft  gum  (Nelaton's) 
catheter  (Fig.  240)  is  lubricated  with  glycerin,  and  is  introduced  as  far  as 
the  compressor-urcthrae  muscle.  A  hand-syringe  holding  about  four  ounces 
of  fluid  is  filled  with  the  solution,  which  is  then  injected  into  the  catheter. 


TREATMENT  OF  GONORRHCEA. 


305 


and  will  be  seen  escaping  from  the  meatus  alongside  of  the  instrument. 
After  this  preliminary  washing  of  the  anterior  urethra,  the  patient  is  di- 
rected to  assume  the  recumbent  posture.  The  soft  catheter  is  again  lubri- 
cated, and  is  passed  gently  into  the  bladder.  This  process  will  be  very 
much  facilitated  by  the  injection  of  a  small  quantity  of  glycerin  through 
the  catheter  when  it  is  about  to  pass  the  cut-off  muscle.  A  small  amount 
of  pressure  will  overcome  the  tension  of  the  compressor,  and  the  arrival  of 
the  jDoint  of  the  instrument  in  the  desired  locality  can  be  tested  by  injecting 
an  ounce  or  two  of  the  prepared  lotion.  Should  it  escape  from  the  urethra, 
this  would  be  a  sign  that  the  eye  of  the  catheter  has  not  passed  the  com- 


FiG.  240. — N^latoii's  soft  gum  catheter. 

pressor  muscle.  If,  on  removal  of  the  syringe,  the  lotion  is  seen  to  escape 
at  once  from  the  bladder  through  the  catheter,  then  it  may  be  concluded 
that  the  eye  of  the  catheter  is  in  the  cavity  of  the  bladder,  and  that  it  has 
been  introduced  too  far,  and  needs  to  be  withdrawn  an  inch  or  a  little  more 
or  less.  Should,  on  renewed  injection,  the  lotion  all  enter  the  Madder,  but 
fail  to  escape  through  the  catheter,  this  is  a  positive  sign  that  the  heaJc  of 
the  instrument  is  just  beyond  the  cut-off  muscle — that  is,  in  the  posterior 
part  of  the  membranous  portion.  Fluids  injected  into  this  place  will  readily 
enter  the  bladder,  as  their  pressure  can  easily  overcome  the  internal  sphinc- 
ter ;  but  recontraction  of  this  muscle  will  prevent  their  escape  until  the 
beak  of  the  instrument  is  pushed  into  the  vesical  cavity.  According  to  the 
irritability  of  the  patient,  from  one  to  four  ounces  of  the  lotion  are  slowly 
injected  while  the  point  of  the  catheter  is  located  in  the  space  between  the 
cut-off  and  internal  sphincter  muscles.  As  soon  as  the  patient  complains 
of  pressure,  injection  should  cease,  and  the  catheter  should  be  gently  pushed 
within  the  vesical  cavity,  whence  it  will  at  once  conduct  the  injected  fluid 
into  a  vessel  placed  between  the  thighs  of  the  patient.  It  is  better  not  to 
inject  too  large  a  quantity  at  the  beginning,  as  this  is  liable  to  bring  on 
vesical  spasm,  resulting  in  a  violent  and  irresistible  expulsion  both  of  lotion 
and  catheter. 


306 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


The  injections  are  to  be  repeated  in  this  manner  until  the  lotion  is  seen 
to  return  clear  from  the  bladder.  The  final  injection  is  voluntarily  passed 
by  the  patient.  This  is  to  satisfy  him  that  his  bladder  is  empty,  and  that 
the  sensation  of  the  desire  to  urinate  is  not  caused  by  retained  fluid. 

The  improvement  following  this  procedure  is  very  apparent,  though  not 
lasting,  and  daily  repetition  will  be  necessary  until  the  frequency  of  mic- 
turition will  have  been  very  materially  reduced. 

The  author  has  never  seen  any  untoward  consequences  following  this 
gentle  and  very  efficient  mode  of  treating  deep-seated  urethral  gonorrhoea. 
The  danger  of  cystitis  or  inflammation  of  the  testicle  will  be  rather  abated 
than  increased  by  this  treatment  if  it  be  carried  out  properly  and  without 
A'iolence.  The  possibility  of  performing  the  entire  procedure  without  any 
abrasion,  undue  pressure,  or  injury  of  the  inflamed  jDarts,  ranks  it  high 
above  all  measures  in  which  unyielding  sounds,  catheters,  or  caustic  holders 
are  placed  in  the  neck  of  the  bladder  for  purposes  of  cauterization.  Their 
use  is  often  followed  by  epididymitis,  and  is  deservedly  held  in  bad  repute. 

Where  the  affection  extends  over  the  whole  urethra,  treatment  of  the 

neck  of  the  bladder  and  of  the  anterior  urethra  can  and  ought  to  be  carried 

out  simultaneously  until  the  secretion  escaping  from  the  meatus  be  reduced 

to  a  minimum,  and  until  the  frequent  urgency  to  urinate  and  the  turbidity 

of  the  water  give  way  to  a  marked  extent. 

Gonorrhceal  catarrh  of  the  neck  of  the  Madder  should  not  be 
mistahen  for  acute  cystitis.     Pus  will  be  found  in  the  urine  in 


^e.T,iEJviAMjg-Ac.o:: 


Fig.  241. — Ultzmann's  prostatic  syringe. 

both  cases,  but  in  cystitis  febrile  disturbances  accompanied  by  alteration  of 
the  general  health  will  be  observed,  and  pressure  pain  above  the  symphysis 
pubis  will  be  noted  aside  from  the  periodical  pain  located  in  the  perineal 
region,  which  follows  urination,  and  which  is  the  diagnostic  sign  of  the 

affection  of  the 
deep  urethra  only. 
Should  irriga- 
tion of  the  deep 
urethra  not  effect 
rapid  or  complete 
cessation   of    the 


^■\^WV.NyMV^,V^  kWRt^tCQ. 


Fig.  242. — Keyes's  modification  of  Ultzmann's  deep  urethral  syringe. 


affection,  instillation  of  a  feto  drops  of  a  five-per-cent  solution  of  nitrate  of 
silver  will  be  found  very  beneficial.  This  is  done  by  Nelaton's  catheter  or 
Ultzmann's  deep  urethral  syringe.  (Figs.  241  and  242.)  The  point  of  the 
filled  instrument  is  dipped  in  glycerin,  and  is  gently  introduced  just  within 
the  compressor-urethraa  muscle.  When  the  barrel  of  the  syringe  is  at  an 
angle  of  forty-five  degrees  with  the  body  of  the  recumbent  patient,  its  beak 
is  just  within  the  neck  of  the  bladder.  Three,  four,  or  five  drops  of  the 
nitrate-of-silver  solution  are  expelled  from  the  syringe,  and  enter  the  deep 


TREATMENT  OF  GONORRHCEA. 


307 


urethra.  Intense  smarting  and  spasm  of  the  neck  of  the  bladder  follow  the 
injection,  but  soon  disappear  if  the  patient  retain  the  reclining  posture  for 
a  short  while. 

These  deep  injections  of  nitrate  of  silver  are  a  very  effective  though 
painful  means  of  checking  a  gonorrhceal  inflammation  of  the  deep  urethra, 
and  deserve  more  frequent  employment  than  they  receive  at  present.  The 
procedure  does  not  entail  any  danger,  and  is  rather  a  preventive  than  a 
cause  of  epididymitis  or  cystitis. 

3.  Chronic  Gonorrlioea.    Gleet : 

a.  IXFLAMMATORT  StENOSIS  (INCIPIENT  StRICTURE)  AND 

Permanent  or  Cicatricial  Stricture  of  the  Urethra  : 

(a)  Anterior  Urethra. — The  termination  of  acute  gonor- 
rhoea is  never  abrupt.  It  is  always  inaugurated  by  a  period 
characterized  by  the  escape  of  a  scanty  amount  of  purulent 
discharge.  During  this  period  subacute  attacks  or  relapses 
of  the  affection  may  be  precipitated  by  any  cause  inducing 
hyperaemia  of  the  urethral  mucous  membrane.  Sexual  irrita- 
tion, alcoholic  indulgence,  severe  bodily  exercise,  offer  mainly 
occasions  for  this  occurrence. 

When  an  acute  gonorrhoea  has  reached  this  stage,  the  prog- 
ress of  the  recovery  often  seems  to  suffer  a  halt,  due  princi- 
pally to  secondary  hyperplastic  changes  of  the  mucous  and 
submucous  tissues.  The  daily  introduction  of  a  full-sized 
sound  or  bougie  for  a  week  or  two  is  generally  sufficient  to 
produce  rapid  absorption  of  the  interstitial  exudation  and  a 
permanent  cure. 

A  contracted  meatus  is  an  effective  impediment  to  the 
application  of  the  sound,  and  requires  an  adequate  division 
of  the  narrow  urethral  orifice.  Meatotomy,  however,  should 
never  he  carried  too  far,  its  only  object  being  the  easy  admis- 
sion of  a  full-sized  steel  sound.  It  is  made  with  a  blunt- 
pointed  tenotomy  knife,  and  the  haemorrhage  caused  by  it 
can  be  easily  checked  by  the  introduction  of  a  small  pledget 
of  iodoformed  gauze  into  the  slit. 

Should  the  patient  positively  decline  meatotomy,  blunt 
dilatation  of  the  part  of  the  urethra,  which  is  the  seat  of  the 
inflammatory  swelling  and  contraction,  can  be  done  by  Otis' s 
urethrometer.     (Fig.  243.)     The  closed  instrument  is  intro- 
duced beyond  the  coarctation,  then  it  is  opened  until  the  dial 
indicates  that  the  bulb  has  been  dilated  to  full  caliber,  and 
then  it  is  drawn  with  some  force  through  the  narrowed  portion  of  the 
urethra.     The  author  has  seen  very  good  results  follow  this  use  of  Otis's 
instrument,  though  the  procedure  does  not  deserve  preference  over  mea- 
totomy and  dilatation  by  the  steel  sound. 

The  absorption  and  disappearance  of  these  "incipient  strictures"  is  very 
much  hastened  by  the  local  application  of  a  strong  (five-per-cent)  solution 


308  RULES  OF  ASEPTIC   AND  ANTISEPTIC   SURGERY. 

of  nitrate  of  silver.     To  enable  an  exact  application  of  the  caustic  under  the 
gtiidatice  of  the  eye,  the  endoscope  must  he  used. 

The  endoscope  is  a  cylindrical  silver  tube  of  from  four  to  six  inches  in 
length,  and  of  various  calibers.  (Fig.  244.)  An  obturator  facilitates  its 
painless  introduction,  and  a  flange  or  shield  made  of  hard  rubber,  having  a 
"dead  finish,"  permits  an  easy  handling  of  the  instrument.  Strong  arti- 
ficial light  or  sunlight  is  needed  for  endoscopy.  The  patient  reclines  on  a 
tall  chair,  or  sits  on  the  edge  of  a  table,  his  back  supported  by  a  suitable 
rest,  the  examiner  occupying  the  space  between  the  patient's  legs.  To  pro- 
tect the  patient's  clothing  against  soiling  with  blood  or  chemicals,  a  piece 
of  rubber  cloth  (eighteen  inches  square),  jDrovided  with  a  small  central  slit 
just  long  enough  to  permit  the  slipping  through  of  the  penis,  is  spread  on 
the  pubic  region.    Thus  the  only  object  exposed  to  view  will  be  the  patient's 


Fig.  244. — Klotz's  urethral  endoscope.  wBh 

penis.  Over  the  rubber  cloth  a  clean  towel  is  laid  for  wiping  off  fingers, 
etc.  A  basin  containing  a  number  of  slender  match-sticks,  their  ends 
armed  with  tufts  of  absorbent  cotton,  is  at  hand,  and  a  pus-basin  is  next  to 
it,  to  receive  the  soiled  sticks.  On  a  little  table  adjoining  the  operating- 
chair  are  a  small,  wide-mouthed  bottle  of  glycerin  and  a  few  glass  salt- 
cellars or  hour-glasses  for  the  reception  of  such  solutions  as  may  be  required. 
Of  these  the  author  uses  two — a  five-per-cent  solution  of  nitrate  of  silver 
and  a  ten-per-cent  solution  of  the  same  substance,  both  in  dark  bottles. 

An  endoscopic  tube  of  suitable  size  being  selected,  it  is  lubricated  with 
a  little  glycerin,  and  is  introduced  well  into  the  bulbous  portion  of  the  ure- 
thra. The  obturator  is  withdrawn,  and  the  surgeon  by  his  head-mirror 
directs  a  ray  of  sun-  or  lamp-light  into  the  bottom  of  the  tube,  where  the 
mucous  membrane  of  the  urethra  is  visible  in  the  shape  of  a  tyjDical  image, 
consisting  of  several  concentric  folds  uniting  to  a  central,  funnel-shaped 
depression. 

In  sunlight  the  normal  mucous  membrane  is  pale,  of  about  the  same  hue 
as  the  normal  buccal  lining,  and  on  it  are  visible  a  number  of  delicate  trac- 
ings, produced  by  minute  vessels.  It  is  very  smooth  and  glossy,  and  the 
folds  of  the  image  are  flexible  and  rather  delicate,  and  present  7io  change  of 
color  on  deej)er  introduction  or  withdraival  of  the  tube. 

Inflamed  urethrm  show  an  entirely  diffei'ent  aspect.  The  most  delicate 
manner  of  introducing  the  instrument  is  apt  to  cause  slight  hgemorrhage, 
which  sometimes  is  very  troublesome,  as  the  blood  fills  up  the  tube  faster 
than  it  can  be  mopped  aAvay,  frustrating  for  the  time  being  all  further 
manipulation.  When  the  mucous  membrane,  exposed  in  the  bottom  of  the 
endoscope,  is  dried  off  with  a  pledget  of  cotton,  it  has  a  dull,  dead  gloss. 


TREATMENT  OF  GONOREHCEA.  309 

or  velvety  appearance ;  it  shows  a  more  or  less  intense,  uniform  shade  of 
red,  scarlet,  or  purple.  The  folds  of  the  endoscopic  image  are  few  and 
coarse,  and  not  so  flexible  as  those  of  the  normal  nrethra. 

Gradually  withdrawing  the  tube  with  short  stops,  the  entire  length  of 
the  urethra  can  be  thus  inspected. 

In  chronic  gonorrhceal  urethritis  the  inflammation  will  be  found  limited 
to  more  or  less  well-circumscribed  portions  of  the  urethra.  These  parts, 
examined  by  urethrometer  or  bulbous  bougie,  quite  frequently  show  a  well- 
marked  though  moderate  contraction,  which  can  also  be  demonstrated  to 
the  eye  through  the  endoscope. 

In  withdrawing  the  tube,  new  parts  of  either  normal  or  uniformly  red, 
inflamed  mucous  membrane  will  j^resent  themselves  to  the  examiner's  eye. 
Suddenly,  however,  the  field  of  vision  will  become  pale.,  perfectly  ancemic, 
and  ivory-colored.     This  change  of  color  is 
due  to  depletion  of  blood  and  the  ansemia  of 
the  constricted  part  of  the  urethra,  caused 
by  the  distention  produced  by  the  dilating     p^^_  245.-Metaiiic  buiboTb^ugie. 
instrument.    As  soon  as  the  end  of  the  tube 

is  withdrawn  from  the  stenosed  part,  the  formerly  bloodless  tissues  are  seen 
to  suddenly  flush  up  and  become  of  exactly  the  same  color  as  the  rest  of  the 
inflamed  mucous  membrane.  Examination  by  the  bulbous  bougie  (Fig.  245) 
will  show  that  the  seat  of  this  phenomenon  corresponds  exactly  with  the 
locality  of  the  narrowing  of  the  urethral  caliber. 

In  cases  where  gleet  has  persisted  for  several  months,  these  constricted 
places  appear  in  the  endoscope  of  a  pearly  color,  which  is  due  to  the  con- 
siderable thickening  of  the  epithelial  layer. 

The  application  of  the  nitrate-of-silver  solution  to  these  '' incipient  strict- 
ures "  will  be  found  to  materially  hasten  their  absorption,  if  it  be  supple- 
mented by  the  introduction  of  a  full-sized  sound.  The  applications  are 
made  through  the  endoscope  every  other  day  with  a  cameFs-hair  brash  or  a 
wad  of  absorbent  cotton  fastened  to  the  end  of  a  long  match-stick.  They 
cause  a  slight  smarting,  which  does  not  persist  very  long.  Occasionally 
they  are  followed  by  slight  htemorrhage  on  the  day  subsequent  to  the  ap^Dli- 
cation,  which,  however,  is  without  any  significance. 

Most  of  these  '•' incipient  strictures"  get  well  iTuder  the  treatment  just 
described,  and  do  not  require  urethrotomy. 

But,  when  the  embryonic  connective  tissue  of  these  stenoses  of  inflam- 
matory character  becomes  definitely  transformed  into  fibrillar  connective 
tissue — that  is,  a  fully  developed  cicatrix — it  represents  a  permanent — that 
is,  orgaiiic — stricture  that  can  not  be  cured  by  simple  dilatation  and  topical 
applications.  True,  it  may  be  gradually  dilated  to  the  normal  caliber,  but 
the  dilatation  will  be  evanescent,  and  speedy  recontraction  will  follow  the 
cessation  of  the  treatment. 

The  appearance  of  a  cicatricial  or  permanent  stricture  in  the  endoscopic 
field  of  vision  differs  in  many  ways  from  that  of  an  inflammatory  stenosis. 
This  diagnostic  distinction  is  all  the  more  valuable,  as  an  examination  by 
41 


310  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

the  bulbous  bougie,  although  capable  of  demonstrating  the  presence  of  a 
narrowing  of  the  urethral  caliber,  does  not  divulge  anything  regarding  the 
nature  of  the  stenosis. 

The  most  characteristic  feature  of  permanent  strictures  is  the  unchang- 
ing anaemic,  pale  condition  of  the  mucous  membrane  about  the  stricture 
in  the  endoscopic  field  of  vision.  The  sudden  flushing  up  on  withdrawal 
of  the  endoscoj)ic  tube,  seen  in  the  contractions  of  recent  date,  is  absent. 
The  second  characteristic  is  the  peculiar  rigidity  of  the  urethral  ivall  at 
the  site  of  the  stricture.  On  withdrawing  the  endoscope,  the  rigid  walls 
of  the  urethra  show  a  tendency  to  remain  patulous,  so  that,  instead  of  a 
small  and  rapidly  changing  image  of  soft,  pliable  mucous  membrane,  a 
comparatively  long  stretch  of  the  urethra  can  be  looked  over  at  a  glance, 
resembling  somewhat  the  walls  of  a  short  tunnel. 

Absorption  and  disappearance  of  a  cicatricial  stricture  are  a  very  excep- 
tional occurrence,  whether  it  be  subjected  to  treatment  or  not.  To  suffi- 
ciently 2viden  a  strictured  urethra,  urethrotomy,  followed  hy  methodical 
dilatation,  is  required. 

Such  a  cure  as  is  not  infrequently  observed  to  come  from  treatment  of 
an  inflammatory  stenosis — that  is,  a  perfect  restitution  of  the  normal  state 
of  affairs — is  never  to  he  expected  after  the  treatment  of  a  cicatricial  stricture, 
he  this  treatment  dilatation  alone,  or  cutting  comhined  loith  suhsequent  dila- 
tation. The  cicatricial  ring  will  become  wider  than  before,  but  its  rigidity 
and  unnatural  appearance  will  remain  unchanged. 

The  cases  in  which  the  cicatricial  bands  can  be  divided  in  their  entirety 
yield  the  comparatively  best  results.  But  the  worst  strictures  involve  the 
entire  thickness  of  the  spongy  part  of  the  urethra,  and  to  effect  complete 
division  in  these  cases  the  entire  thickness  of  the  urethra  would  have  to  be 
cut  through,  which  is  an  impracticable  and  sometimes  dangerous  procedure. 

Case. — M.  F.,  aged  forty-two,  had  a  series  of  old  cicatricial  strictures  involving  the 
entire  anterior  portion  of  the  urethra.  One  seated  in  the  fossa  navicularis  was  very 
tight,  another  one  at  the  bulbo-membranous  junction  was  very  massive,  so  that  it 
could  be  felt  through  the  peringeum.  Blunt  dilatation  with  steel  sounds,  up  to  No.  34 
of  the  French  scale,  always  produced  cessation  of  the  profuse  discharge,  but,  recontrac- 
tion  to  the  old  condition  always  following  within  forty-eight  hours,  internal  ure- 
throtomy was  decided  on.  August  20, 1885. — The  operation  was  performed  with  Otis's 
urethrotome.  The  urethra  was  dilated  to  No.  30,  and  then  two  parallel  incisions  were 
made  along  the  entire  length  of  the  roof  of  the  pendulous  portion.  Some  hesitation 
of  the  bulbous  bougie  was  noted  at  the  bulbo-membranous  junction,  therefore  Otis's 
instrument  was  reintroduced,  dilated  to  No.  32,  and  the  still  narrow  part  of  the  urethra 
once  more  cut.  Smart  haemorrhage  was  observed,  but  not  more  than  the  length  of 
the  incision  justified,  and  after  some  compression  it  ceased.  On  returning  to  the  pa- 
tient after  the  lapse  of  two  hours,  the  writer  found  him  lying  on  bis  blood-soaked 
mattress  in  a  pool  of  blood,  in  a  most  deplorable  state  of  prostration  and  anxiety.  The 
scrotum  and  penis  were  swollen  out  of  proportion,  and  had  assumed  a  blue-black  color, 
and  blood  was  issuing  from  the  meatus  at  varying  intervals.  A  large  English  web- 
catheter  was  introduced  and  tied  into  the  bladder,  and  only  persistent  digital  pressure 
exerted  over  the  bulbous  portion  for  more  than  two  hours  succeeded  in  arresting  the 


TREATMENT  OF  GONORRHCEA. 


311 


loss  of  blood,  and  cliecked  further  bloody  infiltration  of  the  penile  and  scrotal  tissues. 
Fortunately,  infection  of  the  wound  was  avoided  by  careful  asepsis,  and  thus,  no  fever 
and  inflammation  following,  the  entire  enormous  extravasation  was  readily  absorbed. 
Introduction  of  large  sounds  was  commenced  on  the  twelfth  day,  and  after  a  some- 
what prolonged  convalescence  the  patient  recovered.  "With  the  regular  use  of  the  full- 
sized  steel  sound,  and  an  occasional  irrigation 
of  the  neck  of  the  bladder,  the  patient  suc- 
ceeds in  maintaining  a  very  comfortable  state 
of  health. 

In  the  case  just  related,  complete  di- 
vision of  the  posterior  stricture,  situated 
at  the  bulbo-membranous  junction,  led  to 
the  injury  of  the  bulbar  artery,  imbedded 
in  the  cicatricial  mass  constituting  the 
stricture.  Had  the  wound  been  infected 
by  the  use  of  uncleanly  instruments,  sup- 
puration and  decomposition  of  the  large 
bloody  infiltration  might  have  brought 
the  patient  into  very  great  danger. 

A  serious  objection  to  Otis's  otherwise 
excellent  urethrotome  (Fig.  246)  is  the 
great  difficulty  of  thoroughly  cleansing 
the  complicated  instrument. 

The  autlior  recommends  the  folloioing 
simplified  manner  of  performing  inter- 
nal urethrotomy  of  the  anterior  urethra 
for  strictures  of  wide  caliber.  A  long 
and  stout-shanked,  rather  narrow-bladed, 
blunt-pointed  tenotomy-knife  is  first  in- 
troduced well  beyond  the  ascertained 
depth  of  the  stricture.  Alongside  of 
this,  Otis's  urethrometer  is  inserted  to 
the  same  depth.  The  bulb  of  the  latter 
instrument,  being  well  dilated,  is  drawn 
forward  until  it  is  arrested  by  the  strict- 
ure. While  the  bulb  of  the  urethrome- 
ter is  held  close  to  the  mesial  entrance 
of  the  stricture,  the  tenotomy-knife  is 
grasped  and  its  sharp  edge  is  applied  to 
the  tense  cicatricial  bands.  It  is  drawn 
forward  until  the  blade  is  past  the  con- 
striction. Should  the  bulb  of  the  ure- 
thrometer follow  without  a  halt,  the  stricture  can  be  considered  as  suffi- 
ciently divided ;.  should  the  division  be  insufficient,  the  bulb  of  the  ure- 
thrometer is  closed,  and  the  tenotomy-knife  is  slipped  back  past  the  stricture 
to  repeat  the  process  of  cutting.     Thus  the  surgeon  is  sure  of  dividing  only 


312 


RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 


the  stricture,  and  not  cutting  deeper  than  necessary  to  permit  the  passage 
of  the  dilated  bulb.  The  method  is  both  simple  and  exact,  and  seems  well 
deserving  of  trial. 

For  very  tight  strictures  Maisonneuve's  instrument  is  most  proper. 
(Fig.  247.) 

Careful  disinfection  of  the  surgeon's  hands  and  instruments,  and  irri- 
gation of  the  urethra  with  a  watery  tepid  solution  of  permanganate  of  pot- 
ash (1  :  2,000),  should  precede  every  step  or  oper- 
fation  that  may  lead  to  wounding  of  the  urethral 
^^^  mucous  membrane.     As  a  lubricant,  iodoformized 

vaseline  (1  :  30)  should  be  used.  The  operation 
should  terminate  with  a  renewed  irrigation  of  the 
urethra. 

Whenever  strictures  are  cut  that  have  their  seat 
near  the  bulbo-membranous  junction,  a  new,  large- 

a^  sized,  English  elastic  catheter  should  be  tied  into 

yi  the  bladder  for  twelve  hours,  and  the  patient  should 

be  kept  in  bed  for  a  day  or  two.  These  precautions 
are  rarely  necessary  in  cutting  strictures  located  in 
the  pendulous  portion,  as  it  is  not  difficult  to  pre- 
vent haemorrhage  by  the  application  of  a  compres- 
sory  bandage  to  the  penis.  A  gutter  of  light  paste- 
board is  applied  to  the  under  side  of  the  penis, 
which  is  first  enveloped  in  a  layer  of  cotton,  and 
the  splint  is  firmly  secured  by  a  few  turns  of  a  roller 
bandage.  The  penis  and  scrotum  are  held  up  to 
the  belly  by  a  snugly  fitting  T-bandage.  This  pre- 
ventive appliance  can  be  abandoned  on  the  second 
day  after  the  operation. 

If  ammoniacal  urine  be  present,  its  condition 
should  be  influenced  before  operation  by  the  in- 
ternal administration  of  boracic  acid,  benzoate  of 
soda,  lactic  acid,  or  turjjentine,  so  as  to  become  at 
least  of  neutral,  or  what  is  still  better  of  acid,  re- 
action. 

A  full-sized  steel  sound  is  to  be  introduced  twice 
weekly,  the  first  application  not  to  commence  before 
the  fifth  or  seventh  day  after  the  operation.  Much 
pain  to  the  patient  will  be  avoided  by  first  intro- 
ducing a  copiously  anointed  smaller- sized  sound, 
which  will  carry  a  good  deal  of  the  lubricant  into 
the  urethra,  and  will  render  the  subsequent  use  of  a  full-sized  instrument 
comparatively  painless  and  easy. 

With  the  precautions  above  described,  the  author  has  not  observed  a  case 
of  urethral  fever  following  either  internal  urethrotomy  or  the  use  of  dilat- 
ing instruments  in  the  urethra.     His  experience  extends  over  twenty-one 


TREATMENT  OF  GONORRHCEA.  313 

cases,  in  which  strictures  were  cut  successfully  from  within.  No  febrile  or 
inflammatory  complications  were  ever  observed. 

{b)  Deep  Urethral  Strictures. — Strictures  of  the  deep  urethra  are  located 
in  the  membranous  portion.  Their  development  is  preceded  by  a  stage 
of  epithelial  and  submucous  hyperplasia,  identical  with  the  process  observed 
in  the  anterior  urethra.  This  hyperjolastic  condition  is  amenable  to  suc- 
cessful treatment  by  dilatation  and  caustics,  but  unheeded,  will  develop 
into  permanent  stricture. 

Internal  urethrotomy  of  a  deep-seated  stricture  is  a  much  more  grave 
undertaking  than  the  cutting  of  a  stricture  of  the  anterior  urethra.  Both 
the  danger  of  haemorrhage  and  the  difficulty  of  controlling  it,  should  it 
occur,  render  the  operation  serious.  Haemorrhage  from  the  posterior  part 
of  the  urethra,  lying  behind  the  '^ cut-off"  muscle,  may  long  remain  un- 
recognized on  account  of  the  absence  of  free  bleeding  from  the  meatus,  as 
the  escaping  blood  will  flow  back  into  the  bladder,  and  can  be  expelled  only 
with  the  urine.  For  these  reasons  treatment  by  gradual  dilatation  should 
be  carried  on  whenever  possible,  and  urethrotomy  should  be  reserved  for 
cases  only  that  do  not  yield  to  dilatation  after  patient  trial,  or  will  not 
brook  delay.  When  an  operation  is  decided  on  as  necessary,  external  ure- 
throtomy deserves  the  preference  over  the  internal  operation,  especially  in 
cases  complicated  by  ammoniacal  cystitis.  Haemorrhage  will  be  easy  to 
control.  The  good  drainage  resulting  from  the  external  incision  will  pre- 
vent urine  infiltration,  and  ready  access  to  the  bladder  will  facilitate  anti- 
septic irrigations  of  the  organ. 

External  Urethrotomy. — The  anaesthetized  patient  is  brought  in  the 
lithotomy  position,  his  hands  being  bandaged  to  the  feet,  which  are  then 
wrapped  in  clean  towels,  wrung  out  of  corrosive-sublimate  lotion.  The 
perinseum  and  anal  region  being  shaved  and  rubbed  off  with  the  same 
lotion,  the  operation  begins.  Irrigation  of  the  wound  by  Thiersch's  solu- 
tion is  carried  on  during  the  entire  operation.  When  a  staff  or  even  a  fili- 
form bougie  can  be  carried  into  the  bladder  to  serve  as  a  guide,  the  opera- 
tion will  offer  no  difficulty  whatever.  As  soon  as  the  urethra  is  opened  and 
the  stricture  exjDosed,  its  division  can  be  accomplished  by  the  use  of  a  blunt- 
pointed  tenotomy  knife.  External  urethrotomy  without  a  guide  is  not  as 
easy,  but  its  difficulties  can  be  overcome  by  patience  and  circumspection. 

While  an  assistant  exerts  gentle  pressure  over  the  distended  bladder,  the 
bottom  of  the  urethral  wound  being  well  exposed  by  small,  sharp  retractors 
or  fillets  of  silk  drawn  through  the  lips  of  the  urethral  incision,  one  or  two 
drops  of  urine  will  be  seen  exuding  from  one  or  another  point  of  the  strict- 
ure. A  fine  probe  is  inserted  into  the  point  in  question,  and  will  often 
penetrate  the  stricture.  A  narrow,  grooved  director  is  insinuated  along  the 
probe,  and  serves  to  guide  a  sharp-pointed  tenotomy  knife  through  the  con- 
traction, which  then  can  be  divided  without  difficulty. 

Should  this  expedient  fail,  on  account  of  inflammatory  swelling  of  the 
tight  part  of  the  urethra,  suprapubic  aspiration  of  the  bladder  may  serve  to 
tide  over  the  difficulty.     Eelief  of  the  distention  of  the  bladder  is  often  fol- 


314  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

lowed  by  decrease  of  the  swelling,  and  a  few  hours  after  the  operation  urine 
will  be  found  escaping  through  the  urethra,  when  the  true  channel  can  be 
searched  out  and  dilated. 

Case. — N.  S.,  laborer,  aged  42,  impermeable  stricture  of  the  membranous  portion 
of  the  urethra.  March  11,  1883. — External  urethrotomy  without  guide.  The  stricture 
being  exposed,  most  diligent  search  failed  to  ascertain  the  direction  of  the  channel, 
which  was  obscured  by  the  intumescence  and  great  vascularity  of  the  parts.  The  dis- 
tended bladder  was  finally  emptied  by  snprabubic  aspiration,  and  the  patient  was 
brought  to  bed.  Six  hours  later  the  bladder  had  refilled,  and  urine  was  seen  to  trickle 
from  the  wound  whenever  the  patient  strained.  Eenewed  search  was  rewarded  by 
the  finding  of  the  right  track,  which  was  divided  on  the  grooved  director  without 
much  trouble  or  pain  to  the  patient.     May  20th. — Patient  was  discharged  cured. 

A  modification  of  another  expedient,  proposed  by  the  venerable  Petit, 
was  also  successfully  emi^loyed  by  the  writer. 

Case. — John  Smith,  negro  hostler,  aged  31,  suffered  from  impermeable  stricture 
of  the  deep  urethra  with  dangerous  distension  of  the  bladder.  The  usual  expedients 
for  entering  the  bladder  having  failed,  external  urethrotomy  was  determined  upon, 
and  was  carried  out  December  2,  1876.  The  distal  part  of  the  stricture  being  exposed, 
no  entrance  could  be  effected.  As  there  was  no  aspirating  needle  on  hand,  a  slender 
trocar  was  inserted  into  the  middle  of  the  strictural  mass,  and  was  pushed  forward  in 
the  direction  of  the  urethra,  toward  the  center  of  the  prostate,  under  the  guidance  of 
the  left  index-finger  placed  in  the  rectum.  The  point  of  the  instrument  was  several 
times  caught  in  the  mass  of  the  prostatic  gland,  but  finally  entered  the  median  canal 
and  the  bladder,  this  being  attested  by  the  escape  of  urine.  A  grooved  director  was 
pushed  in  along  the  cannula,  which  was  withdrawn,  and  the  stricture  was  divided 
with  a  tenotomy  knife.  A  sharp  attack  of  fever  and  cystitis  followed,  but  the  patient 
fully  recovered  and  was  discharged  cured  March  5,  187Y. 

Strictures  located  in  the  anterior  urethra  can  be  simultaneously  divided 
by  Otis's  urethrotome  or  the  tenotomy  knife  before  the  patient  recovers 
from  the  anaesthetic.  The  bladder  is  then  washed  out  with  Thiersch's 
solution,  and  the  wound  is  dressed  with  a  pad  of  iodoformed  and  a  compress 
of  sublimated  gauze,  held  in  place  by  a  T-bandage.  In  the  presence  of 
fetid  urine,  the  use  of  a  drainage-tube  is  advisable.  Before  applying  the 
dressings  the  wound  should  be  rubbed  out  with  a  small  sponge  dipped  in 
iodoform  jiowder.  Anointing  of  the  perinaeum  and  buttocks  with  vaseline 
is  necessary  to  prevent  eczema.  The  external  dressings  ought  to  be  changed 
whenever  soaked  ;  the  iodoformed  pads,  however,  should  not  be  disturbed 
without  necessity  as  long  as  they  are  adherent.  Daily  sitz-baths  in  a  weak 
(1  :  10,000)  corrosive-sublimate  solution  will  tend  to  increase  the  comfort 
of  the  patient,  and  will  aid  the  healing  of  the  wound. 

The  daily  introduction  of  a  full-sized  steel  sound  need  not  be  commenced 
before  the  seventh  day,  and  should  be  continued  at  increasing  intervals  for 
at  least  a  year  after  the  operatio7i. 

Altogether,  the  author  iierfonned  external  urethrotomy  seventeen  times. 
Fifteen  patients  recovered,  two  died.     The  fatal  cases  were  as  follows  : 

Case  I. — Mr.  S.  O.,  tailor,  fifty-four  years  old,  suffering  from  tight,  deep-seated 
stricture  of  the  urethra,  complicated  with  purulent  and  fetid  pyelo-nephritis.     The 


TREATMENT  OF  GONOERHCEA.  315 

urine  remained  ammoniucal,  and  the  listula  never  closed.     He  died,  August  5,  1886,  of 
urfBmia,  five  months  after  the  operation,  done  Mai'ch  25,  1886. 

Case  II. — Abraham  Goldfish,  aged  seventy-seven,  suft'ering  from  deep-seated  ure- 
thral stricture,  fetid  cystitis,  and  extensive  urine  infiltration  of  the  perinaium,  due  to  a 
false  passage  made  by  a  physician.  External  urethrotomy  was  performed,  November 
1,  1886,  at  Mount  Sinai  Hospital,  with  much  relief  of  the  subjective  symptoms,  but 
the  patient  succumbed  to  septicaemia  and  septic  nephritis  on  November  18,  1886. 

Of  the  remaining  cases,  one  deserves  special  mention  on  account  of  its 
rarity  : 

Case. — S.  E.,  shopkeeper,  aged  sixty-three,  sustained,  in  1875,  a  compound  fracture 
of  the  left  liorizontal  ramus  of  the  os  puMs,  from  vrhich  he  recovered  after  a  long  term 
of  illness.  In  the  spring  of  1882  increasing  difficulty  of  micturition  became  noticeable, 
and  finally  led  to  retention  of  urine.  June  £5,  1882. — The  author  saw  the  case  in  con- 
sultation with  Dr.  I.  Schnetter.  A  metallic  sound  could  be  passed  easily  as  far  as  the 
membranous  portion,  but  was  there  arrested  by  a  grating,  hard  body,  thought  to  be  a 
sequestrum  or  a  stone.  External  urethrotomy  was  done  June  27th,  and  an  irregularly 
shaped  sequestrum,  one  inch  long  and  one  sixth  of  an  inch  thick,  was  withdrawn  with 
some  difficulty.     Patient  recovered  without  fistula,  and  was  cured  in  about  six  weeks. 

h.  Vegetations  of  the  Urethea. — Venereal  vegetations,  such  as  are 
frequently  observed  under  the  prepuce  of  men  suffering  from  gleet,  occa- 
sionally occur  in  the  urethra,  principally  in  the  fossa  navicularis  and  in 
the  sinus  bulbi.  They  maintain  a  rebellious  urethral  discharge  that  can  be 
stopped  only  by  their  removal.  Their  diagnosis  can  be  made  by  the  aid  of 
the  endoscope,  which  also  affords  the  best  means  of  access  for  their  treat- 
ment. The  use  of  the  curette,  or  a  small  wire  snare,  or  of  chromic  acid  in 
crystals,  will  readily  destroy  them,  and  will  terminate  the  urethral  discharge 
depending  on  their  presence. 

c.  Granular  Urethritis. — One  of  the  most  tedious  affections  of  the 
urethra  is  a  chronic  inflammation  of  the  mucous  membrane  following  an 
attack  of  acute  gonorrhoea,  characterized  by  an  irregularly  distributed  hyper- 
semia  and  scanty  discharge.  The  velvety  mucous  membrane  bleeds  at  the 
slightest  touch,  and  the  condition  resists  every  form  of  local  treatment  for 
a  disproportionately  long  time.  It  seems  that  the  intractability  of  this 
affection  depends  in  a  great  measure  upon  constitutional  disorders  ;  at  least 
the  author  observed  it  most  frequently  in  anaemic  individuals  of  a  scrofulous 
habit.  Measures  directed  to  the  improvement  of  the  general  condition,  and 
supplemented  by  the  local  application  of  a  five-per-cent  solution  of  nitrate 
of  silver  by  the  endoscope,  seem  to  have  been  more  efficient  than  anything 
else,  though  it  must  be  admitted  that  a  few  cases  resisted  every  kind  of 
treatment,  and  had  to  be  given  up  as  entirely  unmanageable. 

d.  Chronic  Catarrh  of  the  Posterior  Part  of  the  Urethra, 
AND  Chronic  Cystitis. — Chronic  catarrh  of  the  membranous  and  prostatic 
part  of  the  urethra  is  frequently  observed  following  an  acute  attack  of  gon- 
orrhoea, in  subjects  formerly  addicted  to  masturbation,  or  those  indulging 
in  general,  and  especially  in  sexual,  excesses.  In  these  cases  no  external 
urethral  discharge  is  visible,  but  frequent  micturition  is  present,  and  both 


316  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

portions  of  the  urine,  passed  into  two  tumblers,  show  turbidity,  the  first 
portion,  however,  being  more  turbid  than  the  last. 

Treatment  by  gradual  dilatation  with  full-sized  sounds  is  perfectly  use- 
less in  this  affection,  and  may  even  lead  to  epididymitis  in  some  cases. 
Methodical  irrigation  of  the  neck  of  the  Madder,  on  the  other  hand,  by  means 
of  a  soft  gum  catheter  and  hand  syringe,  as  described  in  a  preceding  para- 
graph, will  be  very  often  found  beneficial.  Of  all  substances,  a  1  :  2,000 
tepid  solution  of  permanganate  of  potash  has  been  found  most  generally 
applicable.  A  quart  china  bowl  is  filled  with  warm  water,  and  enough  of  a 
concentrated  solution  of  the  salt  is  added  to  tinge  the  water  a  light-claret 
color.  This  test,  by  observing  the  depth  of  the  tinction,  is  very  sensitive 
if  applied  to  weak  solutions,  and  commends  itself  by  its  simplicity.  Next 
to  permanganate  of  potash,  one-]5er-cent  solutions  of  sulpho-carbolate  of 
zinc  or  of  acetate  of  lead  deserve  mention.  But  nitrate  of  silver  is  the 
most  efficient  of  all  hnoion  remedies  in  obstinate  cases  of  chronic  deep-seated 
urethritis  or  prostatic  catarrh.  A  few  drops  of  a  five-per-cent  solution  are 
instilled,  twice  or  three  times  a  week,  by  Ultzmann's  or  Keyes's  deep  ure- 
thral syringe,  as  formerly  described. 

Acute  cystitis,  whether  gonorrhceal  or  pyogenic,  is  not  amenable  to  in- 
strumental treatment,  luhich  should  only  commence  after  the  cessation  of  the 
invasive  stage.  The  object  of  medicinal  irrigation  is  the  disinfection  and 
removal  of  fermenting  urine  and  its  decomposed  contents,  such  as  roj)y 
mucus,  blood,  and  pus. 

If  stone  or  a  stricture  be  the  causative  agents,  they  must  be  removed  ;  if 
imperfect  evacuation  of  the  bladder,  on  account  of  paresis,  or  enlargement 
of  the  prostate,  is  at  the  bottom  of  the  trouble,  regulated  evacuation  of  the 
organ  by  catheterism  must  be  employed.  Aside  from  fulfilling  these  causal 
indications,  recovery  can  be  materially  hastened  by  methodical  irrigation. 

Irrigation  with  a  metallic  '' double  current"  catheter,  as  recommended hy 
various  authors,  is  unsatisfactory.  Introduction  of  the  rigid  catheter  is 
painful,  and  may  be  the  source  of  various  complications.  The  advantages 
of  the  double  current  are  illusory,  as  much  of  the  ropy  mucus  and  other 
sediment  found  in  the  cul-de-sac  of  the  bladder  is  not  brought  out  by  its 
use.  A  more  gentle  and  much  more  efficient  way  of  thoroughly  emptying 
the  deleterious  contents  of  the  inflamed  bladder  is  as  follows  : 

The  patient  is  made  to  stand  before  the  seated  physician.  This  position 
is  more  favorable  than  any  other,  as  in  it  the  sedimental  matter  contained 
in  the  urine  is  made  to  gravitate  toward  the  neck  of  the  bladder,  where  it 
is  readily  stirred  up  and  evenly  distributed  in  the  urine  by  the  injections. 
Thus  it  will  pass  the  catheter  much  easier  than  when  it  forms  a  sticky  mass. 
A  soft  rubber  catheter  is  introduced  into  the  bladder,  and  a  hand-syringeful 
of  a  tepid,  weak  solution  of  cooking-salt  (one  teaspoonful  to  a  quart,  about 
6  :  1,000)  is  thrown  in  gently,  and  is  allowed  to  escape  at  once.  This  is 
repeated  until  the  returning  saline  solution  is  clear  and  limpid.  After  this, 
two  or  four  ounces  of  a  tepid  1  :  5,000  solution  of  permanganate  of  potash 
are  injected  and  retained  for  one  or  two  minutes,  and  the  process  is  repeated 


TREATMENT  OF  GONORRHCEA.  317 

until  the  returning  fluid  ceases  to  be  discolored.  By  and  by,  as  the  bladder 
becomes  more  tolerant,  the  injection  should  be  made  more  forcible,  as  a 
thorough  stirring  up  and  dislodgment  of  the  roi)y  sediment  by  tlie  jet  of 
lotion  is  very  essential  to  its  complete  evacuation.  The  strength  of  the 
medicinal  lotion  should  also  be  gradually  increased  (to  1  :  1,000). 

In  cases  of  paresis,  or  when  a  tendency  to  vesical  haemorrhages  be  pres- 
ent, cold,  instead  of  tepid,  injections  will  be  appropriate. 

In  obstinate  catarrh  the  strength  of  the  permanganate-of-potash  lotion 
can  be  increased  to  3  :  1,000.  Alum  (from  1  :  100  to  5  :  100),  sulphate  of 
zinc  (from  1  :  100  to  2  :  100),  and  nitrate  of  silver  (from  i  :  100  to  2  :  100), 
will  also  be  found  very  effective.  Deodorization  of  fetid  urine  is  readily 
effected  by  injections  of  a  3  :  100  solution  of  resorcine,  which  should  be 
followed  up  by  the  employment  of  one  or  another  of  the  medicinal  solutions 
above  mentioned  (Ultzmann). 

If  the  capacity  of  the  bladder  be  very  much  diminished  by  long-con- 
tinued spastic  contraction  accompanying  gonorrhoeal  or  calculous  cystitis, 
gentle  and  gradual  distention  of  the  organ  by  salt  water  or  medicinal  in- 
jections of  increasing  volume  will  be  followed  by  increasing  tolerance. 
Thus  micturition  will  gradually  become  less  frequent,  and  the  normal  con- 
dition of  things  may  be  re-established. 

Note. — Gradual  distention  of  the  shrunken  bladder  of  elderly  persons  is  dangerous,  as  it 
may  lead  to  rupture  of  diverticula. 


42 


PAET    V. 

SYPHILIS  : 

ASEPTIC    A^D    ANTISEPTIC    TEEATMEJSTT 
OF    ITS    EXTERI^AL    LESIOE^S. 


CHAPTER  X. 

ASEPTICS  AND  ANTISEPTICS  APPLIED    TO  EXTERNAL  SYPHILITIC 

LESIONS. 

1.  Aseptic  Treatment  of  Primary  Induration. — The  nature  of  the  specific 
virus  of  syphilis  is  not  known.  In  most  cases  its  local  and  general  mani- 
festations ai*e  amenable  to  appropriate  systemic  and  topical  remedies. 

It  is  not  intended  here  to  dwell  uj)on  the  nature  and  treatment  of 
syphilis  as  a  general  disease  ;  only  inasmuch  as  some  of  its  more  common 
local  phenomena  require  surgical  treatment  will  their  consideration  be 
deemed  within,  the  limits  of  this  chapter. 

The  anatomical  structure  of  the  primary  induration,  of  tuberous  syphi- 
lides,  and  of  gummy  swellings,  resembles  closely  that  of  recent  tuberculous 
deposits ;  and  their  course  of  development  and  termination  in  central 
coagulation  necrosis,  fatty  changes,  or  caseation,  also  bears  much  general 
resemblance  to  the  affections  caused  by  the  bacillus  of  tuberculosis.  But 
there  is  a  third  point  of  parallelism. 

As  long  as  softened  tuberculous  or  syphilitic  foci  remain  subcutaneous, 
and  are  not  exposed  to  the  influence  of  the  air  and  its  pus-generating  germs, 
their  course  is  bland  and  slow,  and  their  tendency  is  to  fatty  degeneration, 
encapsulation,  and  final  absorption.  But,  as  soon  as  such  a  softening  deposit 
comes  under  the  influence  of  the  pyogenic  elements  contained  in  the  at- 
mospheric air,  its  slow  and  bland  character  is  changed  to  a  most  destructive 
one.  Thus  syphilitic  nodes  of  the  internal  organs,  being  protected  from 
contact  with  the  outer  air,  rarely,  if  ever,  terminate  in  ulcerative  destruc- 
tion :  they  generally  tend  to  fatty  involution,  absorption,  and  cicatrization. 
Specific  deposits  of  the  outer  skin,  the  mucous  membranes — as,  for  example, 
of  the  nasal  and  oral  bones — on  the  other  hand,  are  all  noted  for  their  pro- 
nounced tendency  to  rapid  ulceration  or  gangrenous  destruction. 

As  an  illustration  of  a  parallel  behavior  of  tuberculous  foci,  cold  ab- 
scesses and  articular  tuberculosis  may  be  mentioned.  Before  perforation, 
their  course  is  mild  and  slow  ;  but  after  the  establishment  of  one  or  more 
sinuses  they  become  the  source  of  profuse  secretion,  and  their  course  is 
characterized  by  rapid  local  destruction  with  general  emaciation. 

The  explanation  of  this  peculiar  difference  in  the  behavior  of  syjDhilitic 
indurations  or  tumors,  essentially  identical  in  morbid  character,  is  to  be 
found  in  the  fact  that  the  poor  nutrition  and  low  vitality  of  the  cellular 


322  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

elements  composing  a  primary  or  secondary  syphilitic  node,  exposed  to 
pyogenic  infection  by  contact  with  the  outer  air,  offer  very  favorable  con- 
ditions for  the  rapid  development  and  destrnctive  multiplication  of  germs, 
that  are  notoriously  deleterious  even  to  healthy  tissues.  Pus-generating 
cocci  deposited  on  the  excoriated  surface  of  a  syphilitic  focus,  as,  for  in- 
stance, a  primary  induration  of  the  prepuce,  or  a  gummy  swelling  of  the 
nasal  bones,  will,  by  their  multiplication,  lead  to  massive  invasion  and  raj)id 
ulcerative  destruction  of  the  densely  infiltrated  and  poorly  nourished  node. 

Syphilitic  ulcers  of  every  Tcind  present  a  comhination  of  syphilitic  and  of 
pyogenic  infection. 

If  we  succeed  by  appropriate  systemic  treatment  in  preventing  the  ex- 
tension of  the  central  softening  of  a  syphilitic  node  to  the  surface,  ulcerat- 
ive changes  also  will  thus  be  prevented.  For  example,  the  timely  admin- 
istration of  large  doses  of  iodide  of  potash  may  prevent  necrosis  of  the  nasal 
bones,  which  are  the  seat  of  a  growing  gummy  swelling.  Their  dense  infil- 
tration pertains  to  syphilis  ;  their  necrosis,  however,  is  caused  by  the  invasion 
of  pyogenic  germs.  But  we  possess  another  means  for  preventing  ulcerative 
destruction  of  syphilitic  deposits  located  in  the  outer  skin.  They  are  more 
exposed  to  pyogenic  infection,  but  they  are  also  more  accessible  to  local 
remedies. 

The  aseptic  protection  of  the  surface  of  the  primary  ii^duration  offers  an 
easy  remedy  for  preventing  the  formation  of  the  primary  ulcer  or  chancre. 

True,  that  the  prevention  of  the  ulcerative  destruction  of  a  primary  in- 
duration of  the  prepuce  will  not  prevent  the  systemic  development  of 
syphilis  ;  but  it  will,  nevertheless,  constitute  a  valuable  service  rendered  to 
the  patient,  who  will  be  spared  all  the  suffering,  annoyance,  and  danger 
connected  with  the  development  of  the  primary  ulcer. 

If  a  patient,  exhibiting  a  recent  primary  induration  of  the  penis,  pre- 
sents himself  for  treatment  before  the  appearance  of  the  pustular  excoria- 
tion, or  before  the  epidermal  film  of  the  formed  pustule  is  broken,  and  if 
the  surgeon  thoroughly  cleanses  and  disinfects  the  affected  parts,  afterward 
carefully  enveloping  the  penis  in  an  -aseptic  dry  dressing,  ulceration  of  the 
indurated  node — that  is,  the  development  of  a  primary  ulcer — can  be  efl'ectu- 
ally  prevented. 

The  node  will  lose  its  epidermidal  covering,  but  the  aseptic  dressing  will 
exclude  pyogenic  infection,  and  the  course  of  development  and  involution 
of  the  syphilitic  deposit  will  be  as  though  it  were  subcutaneous.  A  small 
quantity  of  lymph  will  exude  from  the  excoriated  surface,  will  be  imbibed 
by  the  aseptic  dressing,  and  will  exsiccate,  thus  forming  a  hermetic  seal 
and  protection  to  the  diseased  tissues. 

Fatty  disintegration  of  the  infiltrated  tissues  will  be  followed  by  the 
formation  of  new  epidermis,  and  when,  after  three  or  four  weeks,  the  dress- 
ings come  off,  a  cicatrized  though  still  somewhat  indurated  portion  of  skin 
will  be  exposed  to  view. 

Specific  rash,  and  other  manifestations  of  systemic  infection,  will  appear 
in  due  course  of  time  ;  but  the  incalculable  extension  of  the  ulceration  to 


ASEPTICS   AND  ANTISEPTICS  IN  SYPHILITIC  LESIONS.     323 

adjoining  noii-infiltrated  parts  of  the  skin,  and  the  formation  of  suppurat- 
ive bnboes  and  other  complications,  will  be  obviated.  The  following  case 
may  serve  as  an  illustration  : 

Case. — H.  B.,  aged  twenty-tive,  presented  liimself  January  2,  1887,  with  a  hard, 
elevated  node,  the  size  of  a  nickel,  occupying  the  dorsum  penis,  and  another  smaller 
induration  near  the  frenulum.  Suspicious  cohabitation  had  been  indulged  in  for  some 
time  until  within  a  few  days  of  the  visit.  Bilateral  indolent  inguinal  lymphadenitis 
was  noted,  and  the  presence  of  specific  infection  was  assumed.  The  patient  was  kept 
under  daily  observation,  and  was  directed  not  to  meddle  with  any  blister  that  might 
appear  on  the  indurated  spots.  January  8th. — A  yellowish  discoloration  was  observed 
occupying  the  apex  of  the  larger  node,  and  was  looked  upon  as  an  indication  that  a 
pustule  was  forming.  The  entire  penis  was  carefully  cleansed  with  green  soap  and 
warm  water,  and  was  disinfected  with  a  1 : 1,000  solution  of  corrosive  sublimate,  good 
care  being  taken  not  to  break  the  transparent  layer  of  epidermis  covering  the  dis- 
colored spot.  A  thick  layer  of  iodoform  powder  was  sprinkled  over  both  indurated 
nodes,  and  a  small  patch  of  iodoformized  gauze  was  placed  over  them — this  being  held 
down  by  a  narrow,  oblong  compress  of  corrosive-sublimate  gauze,  snugly  bandaged  on 
with  a  muslin  roller.  The  meatus  was  left  exposed  for  micturition,  and  the  patient 
was  directed  not  to  interfere  with  the  dressings  and  to  report  daily.  The  first  dress- 
ing remained  undisturbed  until  January  17th,  when  its  external  part,  getting  disar- 
ranged, was  removed.  The  strip  of  iodoform  gauze  was  found  firmly  attached  to  the 
underlying  indurated  nodes,  and  had  the  appearance  of  a  hard,  flat  cake,  that  had  been 
evidently  soaked  through  by  lymph  or  serum  some  time  since  its  application.  Evap- 
oration of  its  aqueous  contents  had  converted  it  to  the  shape  just  described.  It  was 
left  in  situ,  and  a  fresh  outer  dressing  was  applied. 

At  the  same  date  (January  17th)  the  girl  with  whom  the  patient  had  held  com- 
merce, presented  herself  for  examination  at  the  author's  request,  and  was  found  to  be 
covered  with  a  small,  papulous,  specific  rash.  The  appearance  of  her  throat,  the  uni- 
versal adenitis,  and  two  freshly-cicatrized  spots  on  the  labia  minora,  left  no  doubt  of 
her  being  subject  to  florid  syphilis.  She  remained  under  prolonged  specific  treat- 
ment, and  in  July,  1887.  still  exhibited  pharyngeal  ulcerations. 

January  25th. — The  dressings  applied  to  the  patient's  penis  became  again  disar- 
ranged, and  had  to  be  renewed.  The  immediate  covering  of  the  nodes,  consisting  of 
iodoform  gauze,  was  still  firmly  adherent,  and  was  left  unchanged. 

February  12th. — A  general  maculous  rash  appeared  on  the  patient's  body,  and  sys- 
temic treatment  by  mercurial  inunctions  was  commenced. 

February  20th. — The  entire  dressings  came  off — the  strip  of  iodoform  gauze  in  the 
shape  of  a  perfectly  dry  scab,  to  the  inner  side  of  which  was  found  attached  a  patch 
of  shiny  scales,  consisting  of  effete  epidermis.  The  nodes,  which  were  formerly  promi- 
nent, had  receded  to  the  level  of  the  surrounding  skin,  and  the  induration,  which  still 
could  be  felt,  was  marked  by  a  coat  of  fresh-looking  young  epidermis.  The  patient 
received  fifty  inunctions  of  blue  ointment,  which  freed  him  fi-om  all  cutaneous  symp- 
toms of  the  disease.  In  May,  pharyngeal  ulcerations  appearing,  the  inunctions  were 
resumed.    Size  and  hardness  of  the  initial  sclerosis  were  visibly  diminished  by  this  time. 

It  seems  in  the  foregoing  case  that  the  ulcerative  destruction  of  the  pri- 
mary induration  was  forestalled  by  disinfection  and  subsequent  aseptic 
management.  Without  them  the  imminent  formation  of  an  initial  sore  would 
have  inevitably  occurred.  The  treatment  of  the  fully-developed  chancre 
would  certainly  have  been  a  much  more  disagreeable,  painful,  and  filthy  ex- 


324  RULES  OF  ASEPTIC  AND  ANTISEPTIC  SURGERY. 

perience  than  the  simple  maiiipuhitiou  of  once  cleansing  and  protecting  the 
initial  induration.  The  site  of  the  morbid  process  thus  protected  against  "ex- 
ternal irritation'' — that  is,  pyogenic  infection — ran,  as  it  were,  a  subcuta- 
neous and  bland  course  of  slow  involution,  the  aggregate  of  discharge  during 
forty-three  days  not  exceeding  the  small  quantity  required  to  permeate  a 
strip  of  four  layers  of  iodoformized  gauze,  covering  an  area  of  about  two 
thirds  of  a  square  inch. 

2.  Antiseptic  Treatment  of  the  Primary  Syphilitic  Ulcer. — The  results 
obtained  by  the  various  time-honored  and  well-established  forms  of  local 
treatment  of  the  primary  syphilitic  ulcer  all  bear  out  the  assumption  that 
the  specific  alteration  of  the  affected  tissues  only  serves  as  a  predisposing 
condition  to  the  subsequent  ulcerative  destruction  of  the  initial  sclerosis. 
The  ulceration  is  directly  produced  by  the  ingrafting  of  purulent  infection 
on  a  soil,  devitalized  by  the  dense  cellular  infiltration,  characteristic  of 
initial  sclerosis.  The  rapid  destruction  observed  in  chancre  is  always  sig- 
nalized by  the  detachment  of  the  epidermis  raised  in  the  shape  of  a  pustule, 
under  which  we  find  a  yellowish,  brittle  necrobiotic  nucleus,  which  is  the 
first  to  succumb  to  the  onslaught  of  the  pyogenic  organisms,  deposited  on 
it  by  the  manipulations  of  the  patient  or  otherwise. 

Tlte  various  forms  of  local  treatment  successfully  employed  for  the  cure 
of  cliancre  are  all  antiseptic  in  character. 

Their  aim  is  either  the  prompt  removal  of  the  infectious  discharge  by 
prolonged  baths  and  frequent  moist  dressings,  or  disinfection  by  weak  or 
concentrated  caustics,  or  a  combination  of  measures  directed  toward  a  rapid 
mechanical  removal  of  the  deleterious  secretions,  with  chemical  disinfection. 
As  the  most  powerful  and  most  effective  arrester  of  the  destructive  course 
of  phagedenic  chancre,  the  actual  cautery  is  to  be  mentioned — the  sover- 
eign destroyer  of  all  microbial  parasites. 

a.  Chemical  Sterilization  ked  Sueface  Drai^stage  by  Medicated 
Moist  Dressings. — The  energy  to  be  applied  to  the  local  treatment  of  an 
ulcerating  initial  sclerosis  should  be  proportionate  to  the  virulence  and  de- 
structiveness  of  the  morbid  process.  In  most  cases  the  resistance  of  the 
vital  forces  combating  the  morbid  process  will  be  sufficient  to  check  the 
damage.  This  is  attested  by  the  numerous  cases  of  neglected  chancre  that 
end  ultimately  in  spontaneous  cure.  Hence,  in  most  instances,  a  mild 
treatment  by  local  antiseptic  baths,  combined  with  moist  antiseptic  dress- 
ings, will  answer  the  purpose. 

Frequent  removal  of  the  soiled  dressings  forms  the  most  essential  part 
of  this  plan  of  therapy.  The  patient  is  directed  to  provide  himself  with  a 
wide-mouthed,  one-ounce  vial,  which  is  filled  with  suitably  proportioned 
small,  square  pieces  of  lint  or  gauze,  over  which  is  poured  a  moderate  quan- 
tity of  a  one-per-cent  solution  of  carbolic  acid,  or  a  1  :  5,000  solution  of 
corrosive  sublimate.  The  cork-stoppered  vial  can  be  easily  carried  by  the 
patient,  who  is  enjoined  to  dress  the  sore  or  sores  at  least  once  every  hour, 
and  oftener  if  the  discharge  be  very  profuse.  In  the  morning  and  evening 
a  prolonged  local  bath  in  the  same  solution  is  advisable.     In  many  cases 


ASEPTICS  AND  ANTISEPTICS  IN  SYPHILITIC  LESIONS.     325 

this  plan  will  be  sufficient  to  check  the  extension  of  the  ulcer,  taid  to  bring 
about  cleansing  of  its  bottom. 

Another  mild  form  of  antiseptic  treatment  consists  of  the  application  of 
iodoform  powder  to  the  ulcerating  surface.  The  objectionable  odor  of  the 
drug  can  be  excellently  masked  by  the  admixture  of  equal  parts  of  freshly 
roasted  and  ground  coffee.  As  soon  as  the  appearance  of  a  cicatricial  border 
is  apparent,  these  modes  of  treatment  should  be  abandoned  in  favor  of  the 
application  of  strips  of  mecurial  plaster,  which  should  be  renewed  in  pro- 
portion to  the  amount  of  discharge.  Cicatrization  will  be  very  much  has- 
tened by  this  change. 

h.  Chemical  Sterilization  by  Strong  Caustics. — Cases  of  greater 
virulence  which  do  not  yield  within  a  fortnight  or  so  to  the  mild  plan  of 
treatment  by  scrupulous  cleansing  and  disinfection,  or  in  which  rapid  ex- 
tension of  the  ulcer  does  not  justify  temporizing,  require  the  application  of 
escharotics.  The  author  has  found  a  fifty -per-cent  solution  of  chloride  of 
zinc  the  most  convenient  and  most  effective  of  all  chemicals  recommended 
for  the  cauterization  of  chancre.  Its  application  is  to  be  done  as  follows  : 
The  ulcer  and  its  vicinity  are  subjected  to  a  careful  cleansing  by  a  mop  of 
cotton  dipped  in  a  1  :  1,000  solution  of  corrosive  sublimate.  Crusts  and 
scabs  overlapping  the  edge  of  the  sore  must  be  gently  removed.  A  small 
piece  of  clean  blotting-paper  is  applied  to  the  ulcer  and  its  vicinity  with 
gentle  pressure  to  remove  all  moisture.  A  moderate  quantity  of  the  caustic 
solution  is  applied  to  the  sore  with  a  glass  rod  or  match-stick,  care  being 
taken  not  to  corrode  unnecessarily  the  surrounding  healthy  skin.  Previous 
thorough  drying  of  the  integument  with  blotting-paper  will  best  prevent 
overflowing  of  the  caustic.  All  the  nooks  and  indentations  of  the  margin 
of  the  ulcer  must  be  carefully  covered  by  the  solution.  As  soon  as  the  base 
of  the  sore  assumes  the  color  of  parchment,  which  will  occur  in  from  three 
to  five  minutes,  cauterization  is  completed,  whereupon  the  surplus  of  caustic 
should  be  removed  by  the  application  of  another  piece  of  blotting-paper. 
The  eschar  is  dusted  with  a  little  iodoform  and  coffee-powder,  and  is  pro- 
tected from  injury  by  a  strip  of  moist  lint  or  gauze. 

If  the  cauterization  was  sufficient,  further  extension  of  the  ulcerative 
process  will  be  arrested  thereby.  In  from  two  to  six  days,  according  to  the 
depth  of  the  eschar,  a  narrow  line  of  demarkation  will  appear,  and,  the 
eschar  being  detached,  a  healthy  granulating  surface  will  become  visible. 
This  should  be  dressed  with  strips  of  mercurial  plaster  until  cicatrization  is 
completed. 

Insufficient  chemical  cauterization  will  not  check  the  ulcerative  decay 
of  the  tissues.  In  proportion  to  the  incompleteness  of  the  application,  par- 
tial or  total  extension  of  the  ulcer  will  be  observed.  In  some  cases  only  a 
tongue  of  renewed  ulceration  will  be  seen  extending  outward  from  the  mar- 
gin of  the  eschar.  In  others,  the  ulceration  will  spread  all  around  the 
cauterized  patch,  thus  demonstrating  the  entire  inadequacy  of  the  applica- 
tion.    The  surgeon's  error  should  be  in  favor  of  too  much  rather  than  too 

little  of  the  caustic. 
43 


326 


RULES   OF   ASEPTIC   AND   ANTISEPTIC  SURGERY. 


Wlien  the  process  is  found  to  be  extending  more  or  less  in  spite  of  a  pre- 
vious cauterization,  the  deficiency  should  be  corrected  without  delay  by  a 
renewed  application. 

c.  Sterilization  by  the  Actual  Cautery. — Phagedenic  forms  of 
chancre,  occurring  on  the  penis,  lips,  or  fingers,  and  characterized  by  dusky 
swelling  and  a  rapidly-spreading,  more  or  less  gangrenous  decay  of  the  tissues, 
can  be  rarely  arrested  by  anything  short  of  the  energetic  application  of  the 
actual  cautery.  In  some  cases  renewed  searing  will  be  required  to  check  the 
trouble  brought  under  control  in  one  portion  of  the  ulcer,  but  extending 
further  in  another  direction  from  a  limited  part  of  the  lesion.  It  is  espe- 
cially important  to  search  out  all  recesses  overlapped  by  the  undermined 
margin  of  integument,  as  they  are  the  chief  nidus  of  active  infection.  The 
thermo-cautery,  or  red-hot  iron,  should  be  well  inserted  in  all  of  these  re- 
cesses and  sinuses,  otherwise  the  result  will  be  incomplete  or  entirely  un- 
satisfactory. The  wound  should  be  packed  with  very  narrow  strips  of  iodo- 
form gauze  while  the  patient  is  still  under  the  influence  of  the  indispensable 
anaesthetic,  and  care  should  be  taken  to  line  all  nooks  and  crevices  of  the 
irregular  wound  with  the  gauze.  The  object  of  this  is  to  prevent  retention, 
and  to  secure  prompt  disinfection  of  the  discharges  which  needs  must  he 
absorbed  by  the  dressings.  The  penis  is  enveloped  in  an  ample  compress, 
moistened  with  warm  carbolic  lotion  (one  per  cent),  over  which  is  placed  a 
piece  of  rubber  tissue  to  prevent  evaporation.  On  the  penis,  daily  change 
of  dressings  is  to  be  done  after  a  hip-bath,  which  will  very  much  facilitate 
their  painless  removal.  The  febrile  disturbance  regularly  noted  with  these 
most  virulent  forms  of  specific  ulcer,  and  the 
general  debility  and  anfemia,  which  is  its 
main  predisposing  cause,  require  appropriate 
roborant  and  anti-febrile  general  treatment. 
As  soon  as  cicatrization  shall  have  com- 
menced, the  atfection  is  to  be  treated  like 
a  simple  ulcer. 

The  foregoing  view  of  the  relation  of  sup- 
puration to  syphilitic  lesions  is  based  exclu- 
sively upon  clinical  data,  and  needs  corrobo- 
ration at  the  hands  of  pathologists  more  ex- 
pert in  systematic  and  exact  research  than 
the  author.     One  object  of  these  re- 
marks was   to   arrange   the   clinical 
facts  pertaining  to  syphilitic  ulcera- 
tions under  a  general  principle,  from 
which  the  therapeutic  measures  usu- 
ally employed  for  their  cure  could  be 
easily  and  logically  deduced. 


Viv..  248. — Specific  ulcer  of  inde.K  lintjcr. 


INDEX 


Abdominal  drainage,  138. 

operations,  115. 

suture,  139. 

toilet,  138. 
Abscess,  anal,  254. 

of  bone,  205. 

cervical,  220. 

cold,  264. 

formation  of,  179, 

glandular,  189. 

iliac,  247. 

of  liver,  251. 

lumbar,  251. 

mammary,  223. 

mastoid,  221. 

metastatic,  181. 

pelvic,  246. 

perinephritic,  251. 

perityphlitic,  246. 

prevesical,  247,  249. 

psoas,  246. 

retroperitoneal,  246. 

self-limitation  of,  180. 

tonsillai',  215. 

temporal,  221. 
Accidental  wounds,  29. 
Acetic  acid,  11. 

Active  movements  after  joint  exsection,  278. 
Actual  cautery  for  syphilitic  ulcers,  326. 
Adhesions,  abdominal,  136. 
yEther  pneumonia,  148,  149,  152. 

nephritis,  118. 
Amputations,  59. 

dressings  after,  72. 
Anal  abscess,  254. 
Anal  fistula,  256. 

excision  of,  256. 

suture  of,  257. 

tuberculous,  269. 
Anatomy  of  connective-tissue  planes  of  neck, 
208. 

planes  of  pelvis,  246. 


Anaesthetics  in  herniotomy,  dangerous  depress- 
ing efPect  of,  125. 
Aneurism,  48. 

needle,  48. 
Anchylosis,  bony,  84. 
Ankle-joint,  exsection  of,  293. 
Antisepsis,  27,  167. 

Antiseptics  applied    to  primary  syphilitic  ul- 
cers, 324, 
Apnoea  after  tracheotomy,  101. 
Apparatus  for  the  after-treatment  of  the  ex- 

sected  elbow-joint,  281. 
Aprons,  20. 

Arm,  suppuration  of,  230. 
Arteries, ^ligature  of,  47. 
Artery  forceps,  66. 
Arthrotomy,  75,  79. 

for  elbow  fracture,  SO. 

for  dislocation,  79. 

for  habitual  dislocation,  8. 
Artificial  anaemia,  66. 

anus,  122. 
Aseptic  cap,  89. 
Asepsis,  3. 

in  peritoneal  operations,  115. 
Aseptic  wounds,  5. 

accidental  wounds,  32. 
Aseptics  of  amputation,  59. 

of  the  orifices,  93. 

of  rectum,  154. 
Axilla,  evacuation  of.  111. 
Axillary  glands,  238. 

vein.  111. 

Bacteria  of  putrescence,  171. 

Bismuth,  11. 

Bladder,  antiseptics  of  the,  159. 

treatment  of,  before  ovariotomy,  138. 
Bloodclot,  healing  under  the,  6. 
Bone  abscess,  205. 

tuberculosis,  273. 
Boro-salicylic  lotion,  10. 


328 


INDEX. 


Bose's  methods  of  tracheotomy,  99. 

Bottle-shaped  wounds,  40. 

Bow-leg,  83. 

Bozeman's  position,  154. 

Breast  amputation,  lii9. 

Broad  ligament,  14'2. 

Bursa,  iliac,  230. 

olecranic,  238. 

prepatellary,  242. 

of  quadriceps,  243. 

Cachexia  strumipriva,  108, 
Cancer  of  tongue,  94. 
Caries.  273. 
Carbolic  acid,  10. 
Carpal  exsection,  284. 
Caseation,  264. 
Caseous  infiltration,  264. 
Castration,  152. 
Cataplasms,  186. 
Catgut,  8. 

impure,  8. 

slipping  of,  69 
Catheters,  cleansing  of,  159. 
Catheterism,  159. 
Cervical  abscess,  220. 
Change  of  dressings,  20. 
Chisels,  198. 

Chloride-of-zinc  solution,  825. 
Clap,  301. 

Cleanliness,  surgical,  '7. 
Cleansing  process  of  feet,  61. 
Club-foot,  85. 
Cold  abscess,  264,  273. 

applications,  187. 
Colotomy,  lumbar,  147. 

inguinal,  148. 
Compressor  urethras,  301. 
Continuous  suture,  45. 
Corrosive-sublimate  lotion,  10. 
Coryza,  scrofulous,  269. 
Cotton  dressings,  15. 
"Cut-off"  muscle,  160,  301. 
Cynanche,  parotid,  219. 

sublingual,  217. 
Cyst  of  broad  ligament,  142. 
Cystitis,  315. 
Cystotomy,  perineal,  162. 

suprapubic,  163. 
Czerny's  suture  for  hernia,  130. 

Deformities,  83. 
Diphtheria  of  fauces,  211. 
of  intestine,  125. 


Dissection,  technique  of,  35. 
Dislocation,  irreducible,  79. 

habitual,  79. 
Drainage,  59. 

abdominal,  138. 
Drainage-tubes,  9. 

T-shaped,  for  cystotomy,  164 
Dressings,  11. 

for  hand  and  forearm,  80. 
Dry  dressings,  12. 

spores,  178. 
Dust,  5. 

Elastic  ligatures,  9,  136. 

in  anal  fistula,  258. 
Elbow  apparatus,  281. 

fracture,  80. 

joint,  exsection  of,  280. 
Embolism,  septic,  181. 
Emergencies,  23. 
Emphysematous  gangrene,  191. 
Empyema,  226. 
Endoscoj)e,  urethral,  308. 
Epididymitis,  tuberculous,  269. 
Erysipelas,  170,  259. 

phlegmonous,  260. 
Esmarch's  bandage,  67. 
Estlander's  operation,  228. 
Excii^ion  of  anal  fistula,  256, 
Exsection  of  ankle-joint,  293. 

of  elbow-joint,  280. 

of  joints  for  tuberculosis,  275, 

of  hip-joint,  285. 

of  knee-joint,  287. 

of  shoulder-joint,  278. 

of  wrist,  284. 
External  urethrotomy,  313. 
Extirpation  of  axillary  glands,  289, 

of  cervical  glands,  51,  58. 

of  inguinal  glands,  55,  246. 

of  tumors,  50. 

Eace,  carbuncle  of,  210. 
Fauces,  diphtheria  of,  211, 
Faucial  suppuration,  211. 
Feet,  cleansing  process  of,  61, 
Femur,  necrotomy  of,  203. 
Fibrinous  arthritis,  74. 
Finger-joints,  exsection  of,  238. 

suppuration,  237. 
Fistula  in  ano,  254. 

in  ano,  tubercular,  269. 

thoracic,  228. 
Floating  bodies,  77. 


INDEX. 


329 


Follicular  tonsillitis,  212. 

Fresh  cadavers,  infectiousness  of,  177. 

Funnel-shaped  wounds,  40. 

Gastrostomy,  14(3. 
Gauze,  14. 

corrosive-sublimate,  15. 

iodoformized,  15. 
Giant  cell,  in  tuberculosis,  2(34. 
Glandular  tuberculosis,  269. 
Gleet,  3u7. 
Goitre,  107. 
Gonococcus,  299. 
Gonorrhoea,  299. 

acute,  301. 

anterior,  302. 

chronic,  307. 

deep-seated,  304. 

posterior,  304. 
Granular  urethritis,  315. 
Granulations,  infection  of,  184. 
Gross  dirt,  178. 
Gunshot  wounds,  34. 

Habituation  to  septic  influences,  183. 

Haemorrhoids,  154. 

Hcemostatic  needle,  41. 

Hahn's  incision  for  exsection  of  knee-joint,  288. 

Hand,  phlegmon  of,  230. 

Hernia,  congenital,  130. 

radical  operation  for,  128. 

strangulated,  119. 
Hernial  sac,  ti'eatment  of,  120. 
Herniotomy,  117. 

dressings  after,  127. 
Hilton-Roser's  method  of  incising  abscesses, 

188. 
Hip-rest,  Volkmann's,  127. 
Hip-joint  exsection,  285. 
Hot  applications,  187. 
Hydrocele,  149. 

tapping  of,  150. 
Hygroma,  proliferating,  271. 
Hysterectomy,  143. 

Iliac  abscess,  247. 

bursa,  250. 
Immersion,  continuous,  235. 
Incontinentia  alvi,  258. 
Infection,  portals  of,  171. 
Infectiousness  of  tonsillitis,  214. 
Inflammation,  178. 
Ingrown  toe-nail,  239. 
Inguinal  glands,  245. 


Inguinal  glands,  supi)uration  of,  238,  245. 
Injections,  urethral,  303. 
Instrument-pouch,  26. 
Intermuscular  space,  209,  220. 
Internal  urethrotomy,  311. 
Interrupted  suture,  45. 
Intubation,  213. 
Iodoform,  11. 

dusting  box,  15. 
Irrigation,  7. 

continuous,  235. 

of  joints,  73. 

of  the  neck  of  the  bladder,  304, 

of  the  urethra,  303. 
Irritation,  caloric,  176. 

chemical,  176. 

mechanical,  175. 

Joints,  after-treatment  of,  277. 
Joint-exsection,  275. 
Joints,  suppuration  of,  73. 
tuberculosis  of,  275. 

Kidney,  surgical,  253. 

Klotz's  endoscope,  308. 

Knee-joint  exsection,  technique  of,  288. 

suppuration  of,  242. 

tuberculosis  of,  289. 
Knock-knee,  S3. 

Lange's  position  for  nephrotomy,  252. 

Laparotomy,  exploratory,  133. 

Laryngeal  operations,  97. 

Laryngofissure,  103. 

Larynx,  extirpation  of,  104. 

Laudable  pus,  184. 

Lead-plate  suture.  Lister's,  45. 

Leg,  ulcer  of,  241. 

Leptothrix,  214. 

Ligatures,  8. 

Litliolapaxy,  Bigelow's,  161. 

Little  finger,  suppuration  of,  232. 

Liver  abscess,  251. 

Lumbar  abscess,  251. 

dressings,  254. 
Lupus,  268. 

Lymphadenitis,  caseous,  269. 
Lymphangitis,  185. 

Maas's  operation,  91. 
Mamma,  amputation  of,  109. 
Mammary  abscess,  223. 
Mastitis,  interstitial,  225. 
suppurative,  223. 


330 


INDEX. 


Mastoid  abscess,  221. 

Measles  and  tuberculosis,  265. 

Meatotomy,  307. 

Mechanical  irritation,  175. 

Mikulicz's  operation,  293. 

Moist  dressings,  13. 

Moss,  17. 

Mucous  membranes,  tuberculosis  of,  260. 

Multiple  puncturing,  Volkmanu's,  186. 

Myxa?dema,  loS. 

Nails,  arrangement  of,  84. 

extraction  of,  after  exsection  of  knee-joint, 
293. 

for  knee-joint  exsection,  289. 
Neck  of  the  bladder,  cauterization  of,  306. 

irrigation  of,  304. 
Neck,  caseous  lymphadenitis  of,  270. 

connective-tissue  planes  of,  208. 
Necrosis  of  bone,  193. 

of  gut,  123.  124. 
Necrotomy,  194. 
Needle-holder,  41. 
Nephrectomy,  145 
Neuber's  implantation,  200. 

(Esophagus,  retrograde  cathetcrism  of,  146. 

cancer  of,  146. 
Olecranic  bursa,  238. 
Open  treatment,  66. 
Operating  bag,  25. 
Oral  cavity,  93. 
Orchitis,  tuberculous,  269. 
Osteomyelitis,  acute  infectious,  191. 
Otis's  urethrometer,  307. 
Ovarian  tumors,  140. 

Palmar  bursa,  232. 

suppuration,  231. 
Passive  movements,  75. 

after  joint  exsection,  277. 
Pasteboard  splints,  281. 
Patella,  suturing  of  fractured,  77. 
Pelvic  abscesses,  246. 
Pelvis,  connective-tissue  planes  of,  246. 
Perineoplasty,  91. 
Perinephritic  abscess,  251. 
Peritoneal  tuberculosis,  118. 
Peritonjcum,  protection  of,  138. 
Peritonitis  after  abdominal  section,  117. 
Pcrityphlitic  abscess,  246. 
Perivascular  interspace,  209,  220. 
Pes  valgus,  85. 
Phelps's  operation,  85. 


Phlegmon,  cause  of,  169. 
Phlegmon,  cutaneous,  185. 

retro-pharyngeal,  215. 

subcutaneous,  185. 

subfascial,  189. 

treatment  of,  184. 
Phlegmonous  erysipelas,  190. 
Plastic  operations,  88. 
Pleurisy,  purulent,  226. 
Pneumonia,  from  aether,  148,  149,  152. 
Predisposition  to  tuberculosis,  265. 
Prepatellary  bursa,  242. 
Prevesical  abscess,  247,  249. 
Previsceral  interspace,  208. 
Primary  induration,  syphilitic,  321. 

ulcer,  syphilitic,  322. 
Probing  of  wounds,  193. 
Proctoplasty,  258. 
Prostatic  syringe,  Ultzmann's,  306. 
Pseudo-erysipelas,  260. 
Psoas  abscess,  246. 
Ptomaines,  4. 

Puncture  of  abdominal  tumors,  137. 
Purse-string  suture,  126. 
Putrescence,  bacilli  of,  171. 
Pyaemia,  182. 

Quadriceps,  bursa  of,  243. 
Quilled  suture,  139. 
Quinsy  sore  throat,  215. 

Radical  operation  for  hernia,  128. 

for  hydrocele,  150. 

for  varicocele,  151. 
Rectal  tampon-tube,  155. 
Rectum,  aseptics  of,  154. 
Retractors,  39. 

Retrograde  catheterism  of  oesophagus,  146. 
Retro-peritoneal  abscess,  246. 
Retro-pharyngeal  abscess,  215. 
Retro-visceral  interspace,  208. 
Revision  for  tuberculosis,  274. 
Rose's  position  of  head,  213. 
Rubber  sheets,  arrangement  of,  75,  81). 
Rubber  tissue,  12,  13. 

Sawdust,  16. 

Saws,  disinfection  of,  63. 

Schede's  dressing,  12,  203. 

Schroeder's  suture  of  uterine  stump,  144. 

Scrofula,  269. 

Sepsin,  4. 

Sepsis,  3. 

Sej)tic  fever,  179. 


INDEX. 


331 


Shock  after  laparotomy,  145. 
Shoulder-joint,  exsection  of,  278. 
Sigmund's  urethral  syringe,  303. 
Silk,  9. 

Silk-worm  gut,  'J. 
Soiled  accidental  wounds,  .31. 
Solutions  for  disinfection,  lu. 
Spanish  windlass,  30. 
Splints  of  pasteboard,  280. 
Sponges,  8. 

in  laparotomy,  134. 
Spra}--apparatus,  134. 
Staphylococcus,  169. 
Slarcke's  irrigation-tube,  236. 
Sterilization,  chemical,  7. 
Strangulating  hernial  band,  120. 
Strangulated  hernia,  119. 
Streptococcus,  169. 
Stricture,  urethral,  301. 

incipient,  307. 

permanent  or  cicatricial,  309. 
Styptic  solutions,  abuse  of,  230. 
Submaxillary  capsule,  208,  218. 
Suction  lead,  45.  • 
Suppuration,  cause  of,  169. 

spread  of,  179. 

superficial,  185. 
Suppurations  on  the  face,  209. 

of  the  fauces,  211. 
Surgical  kidney,  253. 
Suture,  abdominal,  139. 

of  anal  fistula,  257. 
Sutures,  8,  43. 

Suturing  fractured  patella,  77. 
Syphilitic  external  lesions,  321. 
Syphilitic  ulcer,  caustic  treatment  of,  325. 

primary,  324. 

moist  treatment  of,  325. 

treatment  by  the  actual  cautery  of,  326. 

T-bandage,  157. 

T-splint,  Volkmann's,  74. 

Tampon  cannula,  Gerster's,  94. 

Tampon-tube,  rectal,  157. 

Temporal  abscess,  22 1 . 

Tendinous  sheaths,  tuberculosis  of,  271. 

Testis,  necrosis  of,  152. 

removal  of,  152. 
Thiersch's  solution,  10. 

spindle-apparatus,  41. 
Thomas's    operation    for    mammary    tumors, 

110. 
Thoracic  fistula,  228. 
Thrombosis  of  pulmonary  artery,  114,  227. 


Thrombosis,  septic,  181. 

venous,  1 14. 
Through-drainage,  46. 
Thumb,  suppuration  of,  232. 
Toilet,  abdominal,  138. 
Tongue,  94. 

Tonsils,  cauterization  of,  213. 
Tonsillar  abscess,  215. 
Tonsillitis,  213. 
Tracheotomy,  preliminary,  94,  97. 

superior,  99. 

inferior,  100. 

for  goitre,  109. 
Trendelenburg's  T-shaped  drainage-tube,  164. 
Trocars,  disinfection  of,  73. 
Tuberculosis,  263. 

of  ankle-joint,  293. 

of  bone,  273. 

cutaneous,  268. 

dissemination  of,  265. 

general  treatment  of,  269. 

of  joints,  275. 

of  knee-joint,  289. 

local  treatment  of,  268. 

of  lymphatic  glands,  269. 

of  mucous  membranes,  269. 

of  peritonseum,  118. 

prevention  of,  289. 

and   pyogenic    infection,    combination    of, 
267. 

of  tendinous  sheaths,  271. 

of  testicle,  269. 
Tuberculous  infection,  direct,  266. 

through  the  lungs,  265. 
Tumors,  extirpation  of,  50. 

Ulcer  of  leg,  241. 

Ultzmann's  method  of  irrigating  the  neck  of 
the  bladder,  304. 

prostatic  syringe,  S06. 

test,  302. 
Uraemia  from  aether,  118. 
Urethral  endoscope,  308. 

injections,  303. 

irrigation,  303. 

stricture,  301. 

syringe,  Sigmund's,  303. 

tuberculosis,  269. 

vegetations,  315. 
Urethritis,  chronic,  315. 

gi'anular,  315. 
Urethrometer,  Otis's,  307. 
Urethroplasty,  90. 
Urethrotomy,  external,  313. 


332 

Urethrotomy,  internal,  311. 
Uterine  stump,  144. 

Yaricocele,  151. 
Vein,  axillary,  111. 
Veins,  exsection  of,  57. 

injury  of  femoral,  56. 

lateral  closure  of,  55. 

treatment  of,  42. 
Venereal  vegetations,  urethral,  315. 


INDEX. 


Vermiform  appendix,  necrosis  of,  124. 
Vertical  suspension  of  limbs,  235. 
Vesical  tuberculosis,  269. 
Volkmann's  hip-rest,  127. 

multiple  puncturing,  186. 

suspension  splint,  235. 

T-splint,  74. 

White  swelling,  275. 


THE     END. 


*:jt*  The  Books  advertised  in  this  List  are  commonly  for  sale  by  booksellers  in 
all  parts  of  the  country  ;  but  any  7vork  will  be  sent  by  D.  Appleton  &  Co.  to  any 
address  in  the  United  States,  postage  prepaid,  on  receipt  of  the  advertised  price. 


CATALOGUE 

OF 

MEDICAL     WO  R  KS. 


THE  PUERPERAL  DISEASES.  Clinical  Lectures  deliv- 
ered at  Eellevue  Hospital.  By  Fordyce  Barker,  M.  D.,  Clinical  Professor 
of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical 
College;  late  Obstetric  Physician  to  Bellevue  Hospital;  Surgeon  to  the 
New  York  State  Woman's  Hospital,  etc. 

Fourth  edition,     i  vol.,  8vo,  526  pp.     Cloth,  $5.00;  sheep,  $6.00. 

"  For  nearly  twenty  years  it  has  been  my  duty,  as  well  as  my  privilege,  to  give  clinical  lectures 
at  Bellevue  Hospital,  on  midwifery,  the  puerperal,  and  the  other  diseases  of  women.  This  volume 
is  made  up  substantrally  from  phonographic  reports  of  the  lectures  which  I  have  given  on  the 
puerperal  diseases.  Having  had  rather  exceptional  opportunities  for  the  study  of  these  diseases, 
I  have  felt  it  to  be  an  imperative  duty  to  utilize,  so  far  as  lay  in  my  power,  the  advantages  which 
I  have  enjoyed  for  the  promotion  of  science,  and,  I  hope,  for  the  interests  ol  humanity." — From 
Aittlwi^s  Preface. 

ON    SEA-SICKNESS.     By  Fordyce  Barker,  M.  D. 

I  vol.,  i6rao,  36  pp.     Flexible  cloth,  75  cents. 

Reprinted  from  the  "  New  York  Medical  Journal."  By  reason  of  the  great  demand  for  the 
number  of  that  Journal  containing  the  paper,  it  is  now  presented  in  book  form,  with  such  prescrip- 
tions added  as  the  author  has  found  useful  in  reUeving  the  suffering  from  sea-sickness. 

PARALYSIS  FROM  BRAIN  DISEASE  IN  ITS  COM- 
MON FORMS.  By  H.  Charlton  Bastian,  M.  A.,  M.  D.,  Fellow  of  the 
Royal  College  of  Physicians  ;  Professor  of  Pathological  Anatomy  in  Uni- 
versity College,  London. 

With  Illustrations,     i  vol.,  i2mo,  340  pp.     Cloth,  $1.75. 

"  These  lectures  were  delivered  in  University  College  Hospital  last  year,  at  a  time  when  I  was 
doing  duty  for  one  of  the  senior  physicians,  and  during  the  same  year — after  they  had  been  repro- 
duced from  very  full  notes  taken  by  my  friend  Mr.  John  Tweedy — they  appeared  in  the  pages  of 
'  The  Lancet.'  They  are  now  republished  at  the  request  of  many  friends,  though  only  after  having 
undergone  a  very  careful  revision,  during  which  a  considerable  quantity  of  new  matter  has  been 
added.  It  would  have  been  easy  to  have  very  much  increased  the  size  of  the  book  by  the  intro 
duction  of  a  larger  number  of  illustrative  cases,  and  by  treatment  of  many  of  the  subjects  at  greater 
length,  but  this  the  author  has  purposely  abstained  from  doing  under  the  belief  that  in  its  present 
form  it  is  likely  to  prove  more  acceptable  to  students,  and  also  perhaps  more  useful  to  busy  prac- 
titioners."— Extract fro7n  Preface. 

THE   MANAGEMENT  OF    INFANCY,  Physiological  and 

Moral.  Intended  chiefly  for  the  Use  of  Parents.  By  Andrew  Combe,  M.  D. 
Revised  and  edited  by  Sir  James  Clark,  K.  C.  B.,  M.  D.,  F.  R.  S.,  Physician- 
in-ordinary  to  the  Queen. 

First  American  from  the  tenth  London  edition,     i  vol.,  i2mo,  302  pp.     Cloth,  $1.50. 
*'  This  excellent  little  book  should  be  in  the  hand  of  every  mother  of  a  family." — The  Lancet. 


2  D.  APPLETON  &-   CO.'S  MEDICAL    WORKS. 

ADOLPH  STRECKER'S  SHORT  TEXT-BOOK  OF  OR- 
GANIC CHEMISTRY.  By  Dr.  Johannes  Wislicenus.  Translated  and 
edited,  with  Extensive  Additions,  by  W.  H.  Hodgkinson,  Ph.  D.,  and  A.  J. 
Greenaway,  F.  I.  C. 

8vo,  789  pp.     Cloth,  $5.00. 

The  great  popularity  which  Professor  Wislicenus's  edition  of  "  Strecker's  Text-Book  of  Or- 
ganic Chemistry  "  has  enjoyed  in  Germany  has  led  to  the  belief  that  an  English  translation  will 
be  acceptable.  Since  the  publication  of  the  book  in  Germany,  the  knowledge  of  organic  chem- 
istry has  increased,  and  this  has  necessitated  many  additions  and  alterations  on  the  part  of  the 
translators. 

Specimen  of  Illustration. 


"Let  no  one  suppose 
that  in  this  '  short  text- 
book '  we  have  to  deal  with 
a  primer.  Everything  is 
comparative,  and  the  term 
'  short '  here  has  relation 
to  the  enormous  develop- 
ment and  extent  of  recent 
organic  chemistry.  This 
soHd  and  comprehensive 
volume  is  intended  to  rep- 
resent the  present  condi- 
tion of  the  science  in  its 
main  facts  and  leading 
principles,  as  demanded 
by  the  systematic  chemical 
student.  We  have  here, 
probably,  the  best  extant 
text-book  of  organic  chem- 
istry. Not  only  is  it  full 
and  comprehensive  and 
remarkably  clear  and  me- 
thodical, but  it  is  up  to  the 
very  latest  moment,  and  it 
has  been,  moreover,  pre- 
pared in  a  way  to  secure 
the  greatest  excellences 
in  such  a  treatise." — The 
Popular  Science  Monthly, 


PRINCIPLES   OF    MENTAL    PHYSIOLOGY,  with  their 

Applications  to  the  Training  and  Discipline  of  the  Mind  and  the  Study  of 
its  Morbid  Conditions.  By  William  B.  Carpenter,  M.  D.,  LL.  D.,  Reg- 
istrar of  the  University  of  London,  etc. 

I  vol.,  8vo,  737  pp.     Cloth,  $3.00. 

"Among  the  numerous  eminent  writers  this  physiological  research  to  the  explanation  of  the  mu- 
country  has  produced,  none  are  more  deserving  of  tual  relations  of  the  mind  and  body  than  Dr.  Car- 
praise  for  having  attempted  to  apply  the  results  of     penter." — The  Lancet. 


HEALTH.      By  VV.   H.  Corfield,   Professor  of  Hygiene  and 

Pul)lic  Health  at  University  College,  London. 
I  vol.,  i2mo.     Cloth,  $1.25. 


"  Few  persons  are  better  qualified  than  Dr.  Cor- 
field to  write  intelligently  upon  the  .subject  of  health, 
and  it  is  not  a  matter  for  surprise,  therefore,  that  he 
has  given  us  a  volume  remarkable  for  accuracy  and 
interest  Commencing  with  general  anatomy,  the 
bones  and  muscles  are  given  attention  ;  next,  the 


circulation  of  the  blood,  then  respiration,  nutrition, 
the  liver,  and  the  execretoiy  organs,  the  nervous 
system,  organs  of  the  senses,  the  health  of  the  indi- 
vidual, air,  foods  and  drinks,  drinking-water,  cli- 
mate, houses  and  towns,  small-pox,  and  communi- 
cable diseases." — Philadelphia  Item. 


D.   APPLETON  (&-   CO:S  MEDICAL    WORKS. 


THE    BRAIN    AS    AN    ORGAN    OF    MIND.       By    H. 

Charlton   Bastian,  M.  A.,  M.  D.,  Fellow  of  the  Royal  College  of  Phy- 
sicians ;  Professor  of  Pathological  Anatomy  in  University  College,  London. 
With  184  Illustrations  and  an  Index.     I  vol.,  i2mo,  708  pp.     Cloth,  $2.50. 

"  This  work  is  the  best  book  of  its  kind.  It  is 
full,  and  at  the  same  time  concise  ;  comprehensive, 
but  confined  to  a  readable  limit ;  and,  though  it 
deals  with  many  subtile  subjects,  it  expounds  them 
in  a  style  which  is  admirable  for  its  clearness  and 
simplicity. " — Nature. 


"  The  fullest  scientific  exposition  yet  published 
of  the  views  held  on  the  subject  of  psychology  by 
the  advanced  physiological  school.  It  teems  with 
new  and  suggestive  ideas." — Lottdon  Athenauni. 


' '  Dr.  Bastian's  new  book  is  one  of  great  value 
and  importance.  The  knowledge  it  gives  is  univer- 
sal in  its  claims,  and  of  moment  to  everybody.  It 
should  be  forthwith  introduced  as  a  manual  into  all 
colleges,  high  schools,  and  normal  schools  in  the 
country  ;  not  to  be  made  a  matter  of  ordinary  me- 
chanical recitations,  but  that  its  subject  may  arrest 
attention  and  rouse  interest,  and  be  lodged  in  the 
minds  of  students  in  connection  with  observations 
and  experiments  that  will  give  reality  to  the  knowl- 
edge required." — Popular  Scie7tce  Monthly. 


TREATISE    ON    MATERIA   MEDICA   AND   THERA- 

PEUTICS.  Revised  and  enlarged.  Edition  of  1883,  with  Complete  Index 
and  Table  of  Contents.  By  Roberts  Bartholow,  M.  A.,  M.  D.,  LL.D., 
Professor  of  Materia  Medica  and  Therapeutics  in  the  Jefferson  Medical  Col- 
lege ;  formerly  Professor  of  the  Theory  and  Practice  of  Medicine,  and  of 
Clinical  Medicine,  and  Professor  of  Materia  Medica  and  Therapeutics  in 
the  Medical  College  of  Ohio,  etc. 

Sixth  edition,  revised  and  enlarged,     i  vol.,  8vo.     Cloth,  $5.00;  sheep,  $6.00. 

"This  edition  of  my  treatise  contains  much  new  matter.  The  domain  of  Pharmacology  is 
rapidly  enlarging  by  the  contributions  of  chemistry,  and  by  new  remedies  brought  forward  by 
dealers  with  a  view  to  profit.  When  a  new  remedy  is  announced,  its  physiological  actions  are 
immediately  studied  and  defined.  ...  As  in  previous  issues  of  this  work,  I  have  sought  to  give 
the  facts,  and  to  some  extent  current  opinions  of  the  time,  on  the  new  remedies ;  but  as  far  as 
possible  demonstrable  incongruities  of  opinion  and  of  practice  have  been  omitted.  Only  by 
actual  inspection  in  all  parts  of  the  work,  as  it  now  appears,  can  the  numerous  additions  to  the 
individual  remedies  be  seen.  ...  I  now  place  the  sixth  edition  before  my  readers  and  the 
medical  profession  in  general,  with  the  expression  of  my  hope  that  it  will  deserve  and  maintain 
the  place  in  their  esteem  which  it  has  always  held." — From  Preface  to  Sixth  Edition. 


"The  very  best  evidence  of  the  success  of  a 
work  is  the  continuous  and  increasing  demand  for 
it.  Bartholow's  '  Materia  Medica  and  Therapeu- 
tics '  has  followed  this  course  since  the  appearance 
of  the  first  edition,  in  June,  1876,  and  has  com- 
pelled the  publishers  to  again  place  before  the  pro- 
fession the  sixth  edition.  In  this  issue  of  the  work 
the  author  has  revised  the  former  edition  most 
carefully,  and  has  included  in  its  pages  the  latest 
and  the  most  valuable  remedies.  About  one  hun- 
dred pages  have  thus  been  added  to  this  valuable 
work,  the  new  contributions  having,  as  the  author 
states,  been  assigned  to  places  according  to  their 
physiological  relations.  The  many  additions,  just 
referred  to,  can  only  be  observed  by  a  careful  ex- 
amination of  all  parts  of  the  book.  .  .  .  The 
work  is  not  only,  as  in  former  editions,  well 
arranged,  but  is  the  most  progressive  one  of  all 
those  now  before  the  profession,  in  the  thorough 
consideration  of  all  therapeutic  measures  of  value 
in  the  treatment  of  disease." — Medical  Register. 

"Since  1876  this  work  has  passed  through  six 
editions,  a  degree  of  favor  which  is  seldom  ac- 
corded to  medical  works.  .  .  .  We  have  written  in 
former  issues  of  the  Journal  our  appreciation  of 
this  volume,  and  we  take  this  occasion  to  say  that 
we  consider  it  essential  to  every  well-selected 
library." — North  Carolina  Medical  yournal. 


"  It  is  to  be  naturally  assumed  that  the  appear- 
ance of  six  editions  of  this  work  in  a  period  of  a 
little  more  than  eleven  years,  is  an  indication  of 
the  measure  of  appreciation  in  which  it  is  held  by 
the  profession.  .  .  .  The  author's  additions  have 
been  extensive  and  important,  and  give  increased 
value  to  a  work  that  is  already  recognized  as  oc- 
cupying a  very  conspicuous  place  in  the  medical 
literature  of  the  day." — College  and  Clinical 
Record. 

"  Since  Bartholow's  '  Materia  Medica '  appeared 
eleven  years  ago,  its  several  editions  have  occupied 
a  place  of  which  its  author  may  well  feel  proud. 
In  the  present  edition  we  find  much  new  matter, 
which,  taken  as  a  whole,  adds  nearly  one  hundred 
pages.  The  'Clinical  Index,'  which  contributes 
greatly  to  the  value  of  the  book,  has  been  retained. 
But  few  books  become  so  popular  as  Bartholow's 
'  Materia  Medica.'  " — Practice. 

' '  Bartholow's  '  Materia  Medica '  is  a  book  too 
well  known  to  the  practitioners  of  medicine  to 
need  at  this  day  any  review.  .  .  .  Unquestionably 
the  new  edition  is  a  great  improvement  on  the  old 
one ;  and  even  if  nothing  were  added  but  a  sum- 
mary statement  about  new  remedies  in  use  since 
the  last  edition,  the  work  would  be  desirable." — 
Gaillard''s  Medical  jfournal. 


D.   APPLE  TON 


C0:S  MEDICAL    WORKS. 


A  TREATISE   ON   THE    PRACTICE   OF   MEDICINE, 

for  the  Use  of  Students  and  Practitioners.  By  Roberts  Bartholow, 
M.  A.,  M.  D.,  LL.  D.,  Professor  of  Materia  Medica  and  General  Therapeu- 
tics in  the  Jefferson  Medical  College  of  Philadelphia ;  recently  Professor  of 
the  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Medical  College 
of  Ohio,  in  Cincinnati,  etc.,  etc. 

!?ixth  edition,  revised  and  enlarged,     i  vol.,  8vo.     Cloth,  $5.00;  sheep  or  half  russia,  $6.00. 

The  same  qualities  and  characteristics  which  have  rendered  the  author's  "Treatise  on  Materia 
Medica  and  Therapeutics  "  so  acceptable  are  equally  manifest  in  this.  It  is  clear,  condensed,  and 
accurate.  The  whole  work  is  brought  up  on  a  level  with,  and  incorporates,  the  latest  acquisitions 
of  medical  science,  and  may  be  depended  on  to  contain  the  most  recent  information  up  to  the  date 
of  publication. 

Specimen  of  Ilu'stration.  i,t-i_     1  i_         ?  1  1 

"The  large  number  of  readers  who  are 

^  ^  already  familiar  with  this  work  will  be  glad 

'•y'-^  to  learn  that  the  present  edition  has  been 

'      ' '  carefully  revised  by  the  author,  considerably 

.^S>  enlarged,  and  is  intended  to  include  all  that 

has  in  the  most  recent  period  been  added  to 
practical  medicine,  especially  in  its  clinical 
,  horizon.     The  author  felicitates  himself  on 

{'^_^  the  large  sales  obtained  for  the  previous  edi- 
'.S  tions,  and  there  is  no  reason  why  the  pres- 
ent one  should  not  continue  to  gain  in  the 
opinion  of  many.  What  doubtless  lends 
the  volume  one  of  its  special  attractions  to 
these  is  the  authoritative  expressions  which 
are  frequent  in  its  pages  on  subjects  where 
the  reader  might  be  left  in  uncertainty  else- 
where. This  remark  applies  both  to  pa- 
thology and  treatment.  The  fullness  with 
which  therapeutics  are  taught  stands  in 
noteworthy  contrast  to  the  majority  of  treat- 
^  ises  on  practice.     This,  too,  is  undoubtedly 

J  .    "/  .  >■.  a  feature  which  will  be  agreeable  to  numer- 

'^U'fi'l'  j"         ,,""    ;'f-  ous  purchasers.      Some  seeming  excess  of 

^^      "  '     i  conciseness  in  certain  portions  is  explained 

by  the  fact  that  this  is  but  one  volume  of  a 
series  proposed  by  the  author,  which  will 
whole  domain  of  special  pathology  and  therapeutics." — Medical  and  Surgical  Reporter. 


cover  the 


' '  That  six  editions  of  such  a  work  should  be 
called  for  in  six  years  is,  perhaps,  the  most  flattering 
testimonial  that  a  book  can  receive,  and  must  out- 
weigh every  other  comment,  favorable  or  unfavor- 
able. In  the  preface  to  this  edition  is  an  announce- 
ment which  will  be  welcomed  by  all  of  Dr.  Bartho- 
low's  numerous  admirers,  namely,  that  he  has  now 
in  preparation  another  work  on  the  '  Principles  of 
Medicine'  which,  together  with  the  one  under  review, 
and  his  'Materia  Medica  and  Therapeutics,'  shall 
constitute  a  trio  of  volumes,  each  containing  matter 
complementary  to  the  others.  Certainly  three  such 
volumes  must  constitute  a  monument  which  will  ren- 
der the  writer's  fame  almost  undying." — Medical 
Press  0/  Western  New  York. 

"  Professor  Bartholow  announces  in  the  preface 
of  this  edition  his  intention  of  preparing  a  work  in 
three  volumes  which  shall  cover  the  whole  domain 
of  special  pathology  and  therapeutics.  The  volume 
on  '  Materia  -Medica '  appeared  some  time  ago,  but 
the  third  volume,  which  will  treat  of  the  '  Principles 
of  .Medicine,'  is  now  in  course  of  careful  preparation, 
and  will,  when  published,  complete  a  most  valuable 
set.  The  present  edition  of  Professor  Bartholow's 
'  Practice '  is  considerably  larger  than  the  last,  several 
new  subjects  having  been  introduced,  together  with 
numerous  new  illustrations.  It  is  deservedly  popu- 
lar with  practitioners  and  students,  and  likely  ere 
long  to  become  one  of  the  standard  works  on  prac- 
tice, if  it  has  not  already  attained  this  position." — 
Pacific  Medical  and  .Surgical  yournal  and  Western 
Lancet, 


"  The  deserved  popularity  of  this  work  is  attested 
by  the  fact  that  the  first  edition  was  issued  in  1880, 
that  a  second  was  demanded  in  three  months,  and 
that  the  others  have  followed  them  in  rapid  suc- 
cession and  been  met  by  appreciative  students  al- 
ways. The  author  says  in  his  preface  to  this  edition 
that  he  has  sought  to  make  it  worthy  of  the  appro- 
bation of  his  readers  by  increasing  the  practical  re- 
sources of  his  work,  devoting  his  attention  chiefly  to 
the  clinical  aspects  of  medicine,  without  overlooking 
the  advances  made  in  the  scientific  branch.  This 
book,  like  the  previous  editions  of  the  work,  is  the 
product  of  a  master  and  an  honored  authority,  and 
in  its  new  form,  with  such  of  the  latest  ideas  as  the 
author  can  conscientiously  indorse  or  present  for 
consideration,  continues  to  hold  its  place  among  the 
standard  text-books  on  all  matters  included  in  it." — 
North  Carolina  Medical  yournal. 

"  This  valuable  work  appears  in  its  sixth  edition 
considerably  enlarged,  and  improved  materially  in 
many  respects.  The  arrangement  of  the  subjects 
appears  to  be  pretty  much  the  .same  as  in  former 
editions,  and  the  description  of  diseases  is  also  little 
modified.  Some  new  chapters  have  been  added, 
however,  and  new  subjects  introduced,  making  the 
volume  completely  cover  the  entire  domain  of  prac- 
tice, without  anything  superfluous.  Considering 
the  immense  scope  of  subjects,  the  directness  of 
statement,  and  the  plain,  terse  manner  of  dealing 
with  the  phenomena  of  disease,  this  practical  work 
has  no  counterpart." — Kansas  City  Medical  Rec- 
ord. 


D.  APPLE  TON  &-   CO:S  MEDICAL    WORKS.  ^ 

ON    THE    ANTAGONISM     BETWEEN     MEDICINES 

AND    BETWEEN    REMEDIES    AND    DISEASES.      Being  the  Cart- 
wright   Lectures  for  the  Year  1880.      By  Roberts    Bartholow,   M.  A., 
M.  D.,  LL.  D.,  Professor  of  Materia  Medica  and  General  Therapeutics  in 
the  Jefferson  Medical  College  of  Philadelphia,  etc.,  etc. 
I  vol.,  8vo.     Cloth,  $1.25. 

"We  are  glad  to  possess,  in  a  form  convenient  no  doubt  that  this,  his  latest  contribution  to  medi- 

for  reference,  this  most  recent  summary  of  the  physi-  cal  science,  will  add  materially  to  his  previously  high 

ological  action  of  important  remedies,  with  the  de-  reputation.     Much   profit,   no   little   pleasure,  and 

ductions  of  a  careful  and  accomplished  observer,  re-  material  assistance  in  the  solution  of  many  thera- 

garding  the  applications  of  this  knowledge  to  dis-  peutical  problems  are  to  be  obtained  from  a  perusal 

eased  states." — College  and  Clinical  Record.  of  these  lectures.     The  author  has  done  wisely  and 

"There   are   few   writers   who  have  taken  the  conferred  a  boon  by  permitting  their  publication  in 

trouble  to  compile  the  lucubrations  of  the  multitude  ^^^  present  book-form,  and  we  are  satisfied  it  wUl 

of  scribblers  who  find  a  specific  in  every  drug  they  ^.e  extensively  asked  for,  and  just  as  extensively  read 

happen  to  prescribe  for  a  self-limited,  non-malig-  ^^  appreciated.  —Canada  Medical  and  Surgical 

nant  disease  ,  and  fewer  who  can  detect  the  trashy  /"'''  '^"-l- 

chaff  and  gamer  only  the  ripe,  plump  grains.    This  ' '  It  will  be  observed  that  the  scope  of  the  work 

Bartholow  has  done,  and  no  one  is  more  ripe,  nor  is  extensive,  and,  in  justice  to  the  author,  not  only 

better  qualified  for  this  herculean  task ;  and,  the  is  the  extent  of  this  indicated,  but  the  character  of 

best  of  all  is,  condense  it  all  in  his  antagonisms.  it  is  also  furnished.     No  one  can  read  the  synopsis 

No  one  can  peruse  its  pregnant  pages  without  no-  given  without  being  impressed  with  the  impjortance 

ticing  the  painstaking  research  and  large  collection  and  diversity  of  the  subjects  considered.     Indeed, 

of  authorities  from  which  he  has  drawn  his  conclu-  most  of  the  important  forces  in  therapeutics  and 

sions.     The  practitioner  who  purchases  these  antag-  materia  medica  are  herein  stated  and  analyzed.  " — 

onisms  wiU  find  himself  better  qualified  to  cope  with  American  Medical  Bi-  Weekly. 

the  multifarious  maladies  after  its  careful  perusal. "  "Probably  most  of   our  readers  wiU  consider 

—Indiana  Medical  Reporter.  that  we  have  awarded  this  treatise  high  praise  when 

' '  The  criticisms  made  upon  these  lectures  have  we  say  that  it  seems  to  us  the  most  carefully  writ- 

invariably  been  most  favorable,  the  topic  itself  is  ten,    best   thought-out,    and    least   dogmatic   work 

one  of  the  most  interesting  in  the  entire  range  of  which  we  have  yet  read  from  the  pen  of  its  author, 

medicine,  and  it  is  treated  of  by  the  accomplished  It  is  indeed  a  very  praiseworthy  book  ;  not  an  origi- 

author  in  a  most  scholarly  manner.     Dr.  Bartholow  nal  research,  indeed,  but,  as  a  resume  of  the  world's 

worthily  ranks  as  one  of  the  best  writers,  while  at  work  upon  the  subject,  the  best  that  has  hitherto 

the  same  time  one  of  the  most  diligent  workers,  in  been    published   in   any   language." — Philadelphia 

the  medical  field  in  all  America,  and  there  can  be  Medical  Times. 

WINTER  AND  SPRING  ON  THE   SHORES  OF  THE 

MEDITERRiVNEAN;    or,    the   Genoese    Rivieras,    Italy,    Spain,    Corfu, 

Greece,  the  Archipelago,  Constantinople,  Corsica,  Sicily,  Sardinia,  Malta, 

Algeria,  Tunis,  Smyrna,  Asia  Minor,  with  Biarritz  and  Arcachon,  as  Winter 

Climates.     By  James  Henry  Bennet,  M.  D.,  Member  of  the  Royal  College 

of  Physicians,  London,  etc.,  etc. 

Fifth  edition.     With  numerous  Illustrations  and  Maps,      i  vol.,  i2mo,  655  pp.     Cloth,  $3.50. 

This  work  embodies  the  experience  of  fifteen  winters  and  springs  passed  by  Dr.  Bennet  on  the 
shores  of  the  Mediterranean,  and  contains  much  valuable  information  for  physicians  in  relation  to 
the  health-restoring  climate  of  the  regions  described. 

"  We  commend  this  book  to  our  readers  as  a  vol-  once  entertaining  and  instructive." — New  York 
ume  presenting  two  capital  qualifications — it  is  at      Medical  Joui-nal. 

ON  THE  TREATMENT  OF  PULMONARY  CON- 
SUMPTION, by  Hygiene,  Climate,  and  Medicine,  in  its  Connection  with 
Modern  Doctrines.  By  James  Henry  Bennet,  M-  D.,  Member  of  the 
Royal  College  of  Physicians,  London ;  Doctor  of  Medicine  of  the  Uni- 
versity of  Paris,  etc.,  etc. 

I  vol.,  thin  8vo,  190  pp.     Cloth,  $1.50. 

An  interesting  and  instructive  work,  written  in  the  strong,  clear,  and  lucid  manner  which  ap- 
pears in  all  the  contributions  of  Dr.  Bennet  to  medical  or  general  literature. 

"We  cordially  commend  this  book  to  the  at-     temperate  climates,  pulmonary  consumption." — Dc' 
tention  of  all,  for  its  practical,  common-sense  views     trait  Review  of  Medicine. 
of  the  nature  and  treatment  of  the  scouige  of  all 


D.   APPLE  TO jY  &-   CO:S  MEDICAL    WORKS. 


GENERAL   SURGICAL    PATHOLOGY  AND  THERA- 

PEUTICS,  in  Fifty-one  Lectures.  A  Text-Book  for  Students  and  Phy- 
sicians. By  Dr.  Theodor  Billroth,  Professor  of  Surgery  in  Vienna. 
With  Additions  by  Dr.  Alexander  von  Winiwarter,  Professor  of  Surgery  in 
Liittich.  Translated  from  the  fourth  German  edition  with  the  special  per- 
mission of  the  author,  and  revised  from  the  tenth  edition,  by  Charles  E. 
Hackley,  A.  M.,  M.  D.,  Physician  to  the  New  York  and  Trinity  Hospitals; 
Member  of  the  New  York  County  Medical  Society,  etc. 
I  vol.,  8vo,  835  pp.     Cloth,  $5.00;  sheep,  $6.00. 


Giant-celled  Sarcoma  with  Cysts  and  Ossifying  Foci  from  the  Lower  Jaw. — Magnified  350  diameters. 

"  Since  this  translation  was  revised  from  the  sixth  German  edition  in  1874,  two  other  editions 
have  been  published.     The  present  revision  is  made  to  correspond  to  the  eighth  German  edition. 
"  Lister's  method  of  antiseptic  treatment  is  referred  to  in  various  places,  and  other  new  points 
that  have  come  up  within  a  few  years  are  discussed. 

"A  chapter  has  been  written  on  amputation  and  resection.  In  all,  there  are  seventy-four 
additional  pages,  with  a  number  of  woodcuts." — Extract  from  Translator'' s  Preface  to  the  Revised 
Edition. 

ture  to  say  no  book  could  more  perfectly  supply 
that  want  than  the  present  volume." — The  Lan- 
cet. 


"  The  want  of  a  book  in  the  English  language, 
presenting  in  a  concise  form  the  views  of  the  Ger- 
man pathologists,  has  long  been  felt,  and  we  ven- 


THE     PHYSIOLOGICAL     AND     THERAPEUTICAL 

ACTION  OF  ERGOT.     Being  the  Joseph  Mather  Smith  Prize  Essay  for 

1881.     By  Etienne  Evetzky,  M.  D. 

I  vol.,  8vo.     Limp  cloth,  $1.00. 

"In  undertaking  the  present  work  my  object  was  to  present  in  a  condensed  manner  all  the 
therapeutic  possibilities  of  ergot.  In  a  task  of  this  nature,  original  research  is  out  of  the  ques- 
tion. No  man's  evidence  is  sufficient  to  establish  the  merits  of  a  drug  considered  in  the  manner 
indicated,  and  no  one  man's  opportunities  are  sufficient  to  grasp  the  entire  subject.  Consequently 
it  remained  to  gather  from  the  volumes  of  past  and  current  periodical  literature  the  testimony  of 
the  multitude  of  physicians  that  had  been  led  to  use  ergot  in  different  morbid  conditions.  I  have 
recorded  everything  that  has  come  to  my  notice,  I  have  grouped  and  classified  the  immense  mate- 
rial in  our  possession.  In  all  cases  in  which  the  action  of  ergot  could  be  explained,  I  have  at- 
tempted to  do  so,  although  this  task  is  frequently  difficult,  if  not  impossible.  .  .  .  The  reader  will 
see  that  ergot  has  been  used  in  a  large  number  of  diseases;  some  of  these  uses  have  little  or  no 
practical  value,  yet  it  is  very  important  to  know  them,  as  they  serve  to  illustrate  the  therapeutic 
properties  of  the  drug.  They  have  been  brought  to  tlie  notice  of  the  reader  without  any  com- 
ments, but  those  that  are  essential  and  of  the  greatest  ]iractical  importance  have  been  dealt  with 
more  fully.  Among  the  latter  may  be  mentioned  the  use  of  ergot  in  inflammation,  aneurism,  car- 
diac diseases,  the  post-parturient  state,  uterine  fibroid  tumors,  rheumatism,  etc." — From  Preface. 


D.   APPLE  TON  &-   CO:S  MEDICAL    WORKS. 


7 


OBSTETRIC  CLINIC.    A  Practical  Contribution  to  the  Study 

of  Obstetrics,  and  the  Diseases  of  Women  and  Children.     By  George  T. 

Elliot,  M.  D.,  late  Professor  of  Obstetrics  and   Diseases  of  Women  and 

Children  in  the  Bellevue  Hospital  Medical  College  ;  Physician  to  Bellevue 

Hospital  and  to  the  New  York  Lying-in  Asylum,  etc, 

I  vol.,  8vo,  458  pp.     Cloth,  $4.50. 

This  work  is,  in  a  measure,  a  resume  of  separate  papers  previously  prepared  by  the  late  Dr. 
Elliot;  and  contains,  besides,  a  record  of  nearly  two  hundred  important  and  difficult  cases  in  mid- 
wifery, selected  from  his  own  practice.  The  cases  thus  collected  represent  faithfully  the  diffi- 
culties, anxieties,  and  disappointments  inseparable  from  the  practice  of  obstetrics,  as  well  as  some 
of  the  successes  for  which  the  profession  are  entitled  to  hope  in  these  arduous  and  responsible 
tasks.  It  has  met  with  a  hearty  reception,  and  has  received  the  highest  encomiums  both  in  this 
country  and  in  Europe. 

THE    SOURCE    OF    MUSCULAR    POWER.     Arguments 

and  Conclusions  drawn  from  Observations  upon  the  Human  Subject  under 
conditions  of  Rest  and  of  Muscular  Exercise.  By  Austin  Flint,  Jr.,  M.  D., 
Professor  of  Physiology  in  the  Bellevue  Hospital  Medical  College,  New 
York,  etc.,  etc. 

I  vol.,  8vo,  103  pp.     Cloth,  $1.00. 

"There  are  few  questions  relating  to  Philosophy  of  greater  interest  and  importance  than  the 
one  which  is  the  subject  of  this  essay.  I  have  attempted  to  present  an  accurate  statement  of  my 
own  observations  and  what  seem  to  me  to  be  the  logical  conclusions  to  be  drawn  from  them,  as 
well  as  from  experiments  made  by  others  upon  the  human  subject  under  conditions  of  rest  and  of 
muscular  exercise." — From  the  Preface. 

ON   THE    PHYSIOLOGICAL   EFFECTS  OF   SEVERE 

AND  PROTRACTED  MUSCULAR  EXERCISE.  With  special  ref- 
erence to  its  Influence  upon  the  Excretion  of  Nitrogen.  By  Austin  Flint, 
Jr.,  M.  D.,  Professor  of  Physiology  in  the  Bellevue  Hospital  Medical  Col- 
lege, New  York,  etc.,  etc. 

I  vol.,  8vo,  91  pp.     Cloth,  $1.00. 

This  monograph  on  the  relations  of  Urea  to  Exercise  is  the  result  of  a  thorough  anil  careful 
investigation  made  in  the  case  of  Mr.  Edward  Payson  Weston,  the  celebrated  pedestrian.  The 
chemical  analyses  were  made  under  the  direction  of  R.  O.  Doremus,  M.  D.,  Professor  of  Chem- 
istry and  Toxicology  in  the  Bellevue  Hospital  Medical  College,  by  Mr.  Oscar  Loew,  his  assistant. 
The  observations  were  made  with  the  co-operation  of  J.  C.  Dalton,  M.  D.,  Professor  of  Physiol- 
ogy in  the  College  of  Physicians  and  Surgeons;  Alexander  B.  Mott,  M.  D.,  Professor  of  Surgical 
Anatomy;  W.  H.  Van  Buren,  M.  D.,  Professor  of  Principles  of  Surgery;  Austin  Flint,  M.  D., 
Professor  of  the  Principles  and  Practice  of  Medicine;  W.  A.  Hammond,  M.  D.,  Professor  of  the 
Diseases  of  the  Mind  and  Nervous  System — all  of  the  Bellevue  Hospital  Medical  College. 

MANUAL  OF  CHEMICAL  EXAMINATION  OF  THE 

URINE  IN  DISEASE.     With  Brief  Directions  for  the  Examination  of 

the  most  Common  Varieties  of  Urinary  Calculi.     By  Austin  Flint,  Jr., 

M.  D.,  Professor  of  Physiology  and  Microscopy  in  the  Bellevue  Hospital 

Medical  College  ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 

Fifth  edition,  revised  and  corrected,     i  vol.,  i2mo,  77  pp.     Cloth,  $1.00. 

The  chief  aim  of  this  little  work  is  to  enable  the  busy  practitioner  to  make  for  himself,  rapidly 
and  easily,  all  ordinary  examinations  of  Urine;  to  give  him  the  benefit  of  the  author's  experience 
in  eliminating  little  difficulties  in  the  manipulations,  and  in  reducing  processes  of  analysis  to  the 
utmost  simplicity  that  is  consistent  with  accuracy. 

"  We  do  not  know  of  any  work  in  Eng;lish  so  reputation  of  the  author  is  a  sufficient  guarantee  of 
complete  and  handy  as  the  Manual  now  offered  to  the  accuracy  of  all  the  directions  given."— Journai 
the  Profession  by  Dr.  Flint,  and  the  high  scientific     of  Applied  C/teimstry. 


8 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


TEXT-BOOK   OF   HUMAN    PHYSIOLOGY,  for  the  Use 

of  Students  and  Practitioners  of  Medicine.  By  Austin  Flint,  Jr.,  M.  D., 
Professor  of  Physiology  and  Physiological  Anatomy  in  the  Bellevue  Hospital 
Medical  College,  New  York  ;  Fellow  of  the  New  York  Academy  of  Medi- 
cine, etc. 

Third  edition.  Revised  and  corrected.  In  one  large  8vo  volume  of  978  pp.,  elegantly  printed  on 
fine  paper,  and  profusely  illustrated  with  three  Lithographic  Plates  and  315  Engravings  on 
Wood.     Cloth,  $6.00;  sheep,  $7.00. 


Stomnch,  Pancreas,  Large  IntLSlme,  etc 

"  The  author  of  this  work  takes  rank  among  the 
very  foremost  physiolojpsts  of  the  day,  and  the  care 
which  he  has  bestowed  in  bringing  this  third  edition 
of  his  text-book  up  to  the  present  position  of  his 
science  is  exhibited  in  every  chapter. " — Medical  and 
Surgical  Jteporter  {Philadelphia). 

"In  the  amount  of  matter  that  it  contains,  in 
the  aptness  and  beauty  of  its  illustrations,  in  the 
variety  of  experiments  described,  in  the  complete- 
ness with  which  it  discusses  the  whole  field  of  human 
physiology,  this  work  surpasses  any  text-book  in 
the  English  language." — Detroit  Lancet. 

"  The  student  and  the  practitioner,  whose  sound 
practice  must  be  based  on  an  intelligent  appreciation 
of  the  principles  of  physiology,  will  herein  find  all  sub- 
jects in  which  they  are  interested  fully  discussed  and 
thoroughly  elaborated." — College  and  Clin.  Record. 

"  We  have  not  the  slighte.st  intention  of  criticis- 
ing the  work  before  us.  The  medical  profession 
and  colleges  have  taken  that  prerogative  out  of  the 


Longitudinal  becLiun  of  the  Human  Larynx, 
showing  the  Vocal  Cords. 


hands  of  the  journalists  by  adopting  it  as  one  of 
their  standard  text-books.  The  work  has  very  few 
equals  and  no  superior  in  our  language,  and  eveiy- 
body  knows  it." — Hahnemannian  Monthly. 

"  We  need  only  say  that  in  this  third  edition  the 
work  has  been  carefully  and  thoroughly  revised.  It 
is  one  of  our  standard  text-books,  and  no  physician's 
library  should  be  without  it.  We  treasure  it  highly, 
shall  give  it  a  choice,  snug,  and  prominent  position 
on  our  shelf,  and  deem  ourselves  fortunate  to  pos- 
sess this  elegant,  comprehensive,  and  authoritative 
work. " — American  Specialist. 

"  Professor  Flint  is  one  of  the  most  practical 
teachers  of  physiology  in  this  country,  and  his  book 
is  eminently  like  the  man.  It  is  very  full  and  com- 
plete, containing  practically  all  the  established  facts 
relating  to  the  different  subjects.  This  edition  con- 
tains a  number  of  important  additions  and  changes, 
besides  numerous  corrections  of  slight  typographical 
and  other  errors,  "r-  Ohio  Medical  Recorder. 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


THE    PHYSIOLOGY  OF  MAN.     Designed  to  represent  the 

Existing  State  of  Physiological  Science  as  applied  to  the  Functions  of  the 
Human  Body.     By  Austin  Flint,  Jr.,  M.  D.,  Professor  of  Physiology  and 
Physiological   Anatomy  in   the   Bellevue   Hospital    Medical   College,  New- 
York;  Fellow  of  the  New  York  Academy  of  Medicine,  etc.,  etc. 
New  and  thoroughly  revised  edition.     In  5  vols.,  8vo.     Per  volume,  doth,  $4.50;  sheep,  $5.50. 

Volume       I.  The  Blood  ;  Circulation  ;  Respiration. 

Volume     II.  Alimentation  ;   Digestion  ;  Absorption  ;  Lymph  and  Chyle. 

Volume  III.   Secretion;    Excretion;     Ductless    Glands;    Nutrition;    Animal 

Heat ;  Movements  ;  Voice  and  Speech. 
Volume    IV.  The  Nervous  System. 
Volume     V.  Special  Senses ;  Generation. 


"  As  a  book  of  general  information  it  will  be 
found  useful  to  the  practitioner,  and,  as  a  book  of 
reference,  invaluable  in  the  hands  of  the  anatomist 
and  physiologist." — Dublin  Quarterly  yourfial  of 
Medical  Scietice. 

"  Dr.  Flint's  reputation  is  sufficient  to  give  a 
character  to  the  book  among  the  profession,  where 
it  will  chiefly  circulate,  and  many  of  the  facts  given 


have  been  verified  by  the  author  in  his  laboratory 
and  in  public  demonstration." — Chicago  Courier. 

' '  The  author  bestows  judicious  care  and  labor. 
Facts  are  selected  with  discrimination,  theories  crit- 
ically examined,  and  conclusions  enunciated  with 
commendable  clearness  and  precision." — American 
Journal  of  the  Medical  Sciences. 


SYPHILIS    AND    MARRIAGE.     Lectures  delivered  at  the 

St.  Louis  Hospital,  Paris.  By  Alfred  Fournier,  Professeur  a  la  Faculte 
de  Medecine  de  Paris ;  Medecin  de  I'Hdpital  Saint-Louis.  Translated  by 
P.  Albert  Morrow,  M.  D.,  Physician  to  the  Skin  and  Venereal  Departmenc_ 
New  York  Dispensary,  etc.,  etc. 

I  vol.,  8vo.     Cloth,  $2.00;  sheep,  $3.00. 

"The  book  supplies  a  want  long  recognized  in 
medical  literature,  and  is  based  upon  a  very  ex- 
tended experience  in  the  special  hospitals  for  syphilis 
of  Paris,  which  have  furnished  the  author  with  a  rich 
and  rare  store  of  clinical  cases,  utilized  by  him  with 
great  discrimination,  originality,  and  clinical  judg- 
ment. It  exhibits  a  profound  knowledge  of  its  sub- 
ject under  all  relations,  united  with  marked  skill  and 
tact  in  treating  the  delicate  social  questions  neces- 
sarily involved  in  such  a  line  of  investigation.  The 
entire  volume  is  full  of  information,  mnemonically 
condensed  into  axiomatic  '  points. '  It  is  a  book  to 
buy,  to  keep,  to  read,  to  profit  by,  and  to  lend  to 
others." — Boston  Medical  and  Stirgical  fota-Jial. 

"  This  work  of  the  able  and  distinguished  French 
syphilographer.  Professor  Fournier,  is  without  doubt 
one  of  the  most  remarkable  and  important  produc- 
tions of  the  day.  Possessing  profound  knowledge 
of  syphilis  in  all  its  protean  forms,  an  unexcelled 
experience,  a  dramatic  force  of  expression,  untinged, 
however,  by  even  a  suspicion  of  exaggeration,  and 
a  rare  tact  in  dealing  with  the  most  delicate  prob- 
lems, he  has  given  to  the  world  a  series  of  lectures 
which,  by  their  fascination  of  style,  compels  atten- 
tion, and  by  their  profundity  of  wisdom  carries  con- 
viction."— St.  Louis  Courier  of  Medicine  and  Col- 
lateral Sciences. 


"Written  with  a  perfect  fairness,  with  a  supe- 
rior ability,  and  in  a  style  which,  without  aiming  at 
effect,  engages,  interests,  persuades,  this  work  is  one 
of  those  which  ought  to  be  immediately  placed  in 
the  hands  of  every  physician  who  desires  not  only 
to  cure  his  patients,  but  to  understand  and  fulfill  his 
duty  as  an  honest  man." — Lyo7i  Medicate. 

'■  No  physician,  who  pretends  to  keep  himself 


informed  upon  the  grave  social  questions  to  which 
this  disease  imparts  an  absorbing  interest,  can  afford 
to  leave  this  valuable  work  unread."  —  St.  Louis 
Clinical  Record. 

' '  The  author  handles  this  grave  social  problem 
without  stint.  A  general  perusal  of  this  work  would 
be  of  untold  benefit  to  society." — Louisville  Medical 
News. 

' '  The  subject  is  treated  by  Professor  Fournier  in 
a  manner  that  is  above  criticism.  Exhaustive  clini- 
cal knowledge,  discriminating  judgment,  and  thor- 
ough honesty  of  opinion  are  united  in  the  author, 
and  he  presents  his  subject  in  a  crisp  and  almost 
dramatic  style,  so  that  it  is  a  positive  pleasure  to 
read  the  book,  apart  from  the  absolute  importance 
of  the  question  of  which  it  treats." — New  York 
Medical  Record. 

' '  Every  page  is  full  of  the  most  practical  and 
plain  advice,  couched  in  vigorous,  emphatic  lan- 
guage."— Detroit  La?tcet. 

' '  The  subject  here  presented  is  one  of  the  most 
important  that  can  engage  the  attention  of  the  pro- 
fession. The  volume  should  be  generally  read,  as 
the  subject-matter  is  of  great  importance  to  society." 
— Maryland  Medical  Journal. 

' '  We  can  give  only  a  very  incomplete  idea  of 
this  work  of  M.  Fournier,  which,  by  its  precision, 
its  clearness,  by  the  forcible  manner  in  which  the 
facts  are  grouped  and  presented,  defies  all  analysis. 
'  Syphilis  and  Marriage '  ought  to  be  read  by  aU 
physicians,  who  will  find  in  it,  first  of  all,  science, 
but  who  will  also  find  in  it,  during  the  hours  they 
devote  to  its  perusal,  a  charming  literary  pleasure.'' 
— Annates  de  Dermatologie  et  de  Syphiligraphie. 


lO 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


CYCLOPAEDIA  OF  PRACTICAL  RECEIPTS,  and  Col- 
lateral Information  in  the  Arts,  Manufactures,  Professions,  and  Trades, 
including  Medicine,  Pharmacy,  and  Domestic  Economy.  Designed  as  a 
Comprehensive  Supplement  to  the  Pharmacopoeia,  and  General  Book  of 
Reference  for  the  Manufacturer,  Tradesman,  Amateur,  and  Heads  of  Fam- 
ilies. Sixth  edition,  revised  and  partly  rewritten  by  Richard  V.  Tuson, 
Professor  of  Chemistry  and  Toxicology  in  the  Royal  Veterinary  College. 
Complete  in  2  vols.,  1,796  pp.     With  Illustrations.     Cloth,  $9.00. 

Cooley's  "  Cyclooajdia  of  Practical  Receipts  "  has  for  many  years  enjoyed  an  extended  reputa- 
tion for  its  accuracy  and  comprehensiveness.  The  sixth  edition,  now  just  completed,  is  larger 
than  the  last  by  some  six  hundred  pages.  Much  greater  space  than  hitherto  is  devoted  to  Hygiene 
(including  sanitation,  the  composition  and  adulteration  of  foods),  as  well  as  to  the  Arts,  Phar- 
macy, Manufacturing  Chemistry,  and  other  subjects  of  importance  to  those  for  whom  the  work  is 
intended.  The  articles  on  what  is  commonly  termed  "Household  Medicine"  have  been  ampli- 
fied and  numerically  increased.    • 

The  design  of  this  work  is  briefly  but  not  completely  expressed  in  its  title-page.  Independ- 
ently of  a  reliable  and  comprehensive  collection  of  formula  and  processes  in  nearly  all  the  indus- 
trial and  useful  arts,  it  contains  a  description  of  the  leading  properties  and  applications  of  the 
substances  referred  to,  together  with  ample  directions,  hints,  data,  and  allied  information,  cal- 
culated to  facilitate  the  development  of  the  practical  value  of  the  book  in  the  shop,  the  laboratory, 
the  factory,  and  the  household.  Notices  of  the  substances  embraced  in  the  Materia  Medica,  in 
addition  to  the  whole  of  their  preparations,  and  numerous  other  animal  and  vegetable  substances 
employed  in  medicine,  as  well  as  most  of  those  used  for  food,  clothing,  and  fuel,  with  their  eco- 
nomic applications,  have  been  included  in  the  \uork.  The  synonyms  and  references  are  other  addi- 
tions which  will  prove  invaluable  to  the  reader.  Lastly,  there  have  been  appended  to  all  the 
principal  articles  referred  to  brief  but  clear  directions  for  determining  their  purity  and  commercial 
value,  and  for  detecting  their  presence  and  proportions  in  compounds.  The  indiscriminate  adop- 
tion of  matter,  without  examination,  has  been  uniformly  avoided,  and  in  no  instance  has  any  form- 
ula or  process  been  admitted  into  this  work,  unless  it  rested  on  some  well-known  fact  of  science, 
had  been  sanctioned  by  usage,  or  come  recommended  by  some  respectable  authority. 

THE  COMPARATIVE  ANATOMY  OF  THE  DOMES- 
TICATED ANIMALS.  By  A.  Chauveau,  Professor  at  the  Lyons  Vet- 
erinary School.  Second  edition,  revised  and  enlarged,  with  the  co-operation 
of  S.  Arloing,  late  Principal  of  Anatomy  at  the  Lyons  Veterinary  School: 
Professor  at  the  Toulouse  Veterinary  School.  Translated  and  edited  by 
George  Fleming,  F.  R.  G.  S.,  M.  A.  I.,  Veterinary  Surgeon,  Royal  Engineers. 
I  vol.,  8vo,  957  pp.     With  450  Illustrations.     Cloth,  $6.00. 


Specimen  of  Illustration. 


"Takinp:  it  altof,'etlier,  the  book  is  a  ver}' wel- 
come addition  to  EnfjHsh  literature,  and  fjreat  credit 
is  due  to  Mr.  Fleming  for  the  excellence  of  the  trans- 
lation, and  the  many  additional  notes  he  has  ap- 
pended to  Chauveau's  treatise." — Lancet  [London). 

"  The  descriptions  of  the  text  are  illustrated  and 


assisted  by  no  less  than  450  excellent  woodcuts.  In 
a  work  which  ranp;es  over  so  vast  a  field  of  anatomi- 
cal detail  and  description,  it  is  difficult  to  select  any 
one  portion  for  review,  but  our  examination  of  it 
enables  us  to  speak  in  high  terms  of  its  general  ex- 
cellence. .  .  ." — Medical  Times  and  Gazette  {Lon- 
don). 


D.  APPLE  TON  &-   CO.'S  MEDICAL    WORKS. 


II 


THE     HISTOLOGY    AND     HISTO-CHEMISTRY    OF 

MAN.  A  Practical  Treatise  on  the  Elements  of  Composition  and  Struc- 
ture of  the  Human  Body.  By  Heinrich  Frey,  Professor  of  Medicine  in 
Zurich.  Translated  from  the  fourth  German  edition,  by  Arthur  E.  J.  Bar- 
ker, Surgeon  to  the  City  of  Dublin  Hospital;  Demonstrator  of  Anatomy, 
Royal  College  of  Surgeons,  Ireland ;  and  revised  by  the  Author.  With  680 
Engravings. 

I  vol.,  8vo,  683  pp.     Cloth,  $5;  sheep,  $6. 

CONTENTS.— 'Yh^  Elements 
of  Composition  and  of  Structure 
of  the  Body :  Elements  of  Com- 
position— Albuminous  or  Protein 
Compounds,  Haemoglobulin,  His- 
togenic  Derivatives  of  the  Albu- 
minous Substances  or  Albumi- 
noids, the  Eatty  Acids  and  Fats, 
the  Carbo-hydrates,  Non-Nitro- 
genous Acids,  Nitrogenous  Acids, 
Amides,  Amido-Acids,  and  Or- 
ganic Bases,  Animal  Coloring 
Matters,  Cyanogen  Compounds, 
Mineral  Constituents ;  Elements  \ 
of  Structure — the  Cell,  the  Origin 
of  the  Remaining  Elements  of 
Tissue;  the  Tissues  of  the  Body 
— Tissues  composed  of  Simple 
Cells,  with  Fluid  Intermediate 
Substance,  Tissues  composed  of 
Simple  Cells,  with  a  small  amount 
of  Solid  Intermediate  Substance, 
Tissues  belonging  to  the  Con- 
nective Substance  Group,  Tissues 
composed  of  Transformed  and, 
as  a  rule.  Cohering  Cells,  with 
Homogeneous,  Scanty,  and  more  or  less  Solid  Intermediate  Substance ;  Composite  Tissues :  The 
Organs  of  the  Body — Organs  of  the  Vegetative  Type,  Organs  of  the  Animal  Group. 


-^<r0j^%\l^. 


Transverse  Section  oi  a  Human  Bone. 


CONSERVATIVE    SURGERY,  as   exhibited   in    remedying 

some  of  the  Mechanical  Causes  that  operate  injuriously  both  in  Health  and 
Disease.  With  Illustrations.  By  Henry  G.  Davis,  M.  D.,  Member  of  the 
American  Medical  Association,  etc.,  etc. 

I  vol.,  8vo,  315  pp.     Cloth,  $3. 

The  author  has  enjoyed  rare  facilities  for  the  study  and  treatment  of  certain  classes  of  disease, 
and  the  records  here  presented  to  the  profession  are  the  gradual  accumulation  of  over  thirty  years' 
investigation. 

"Dr.  Da\is,  bringing  as  he  does  to  his  specialty     deem  it  worthy  of  a  place  in  every  physician's  li- 
a  great  aptitude  for  the  solution  of  mechanical  prob-     brary.     The  style  is  unpretending,  but  trenchant, 
lems,  takes  a  high  rank  as  an  orthopedic  surgeon,     graphic,  and,  best  of  all,  quite  intelligible." — Medi- 
and  his  very  practical  contribution  to  the  literature     cal  Record. 
of  the  subject  is  both  valuable  and  opportune.     We 


YELLOW     FEVER     A     NAUTICAL 

Origin  and  Prevention.     By  John  Gamgee. 


DISEASE.      Its 


I  vol.,  8vo,  207  pp. 

"  The  author  discusses,  with  a  vast  array  of  clear 
and  well-digested  facts,  the  nature  and  prevention 
of  yellow  fever.  The  work  is  admirably  written, 
and  the  author's  theories  plausible  and  well  sus- 
tained by  logical  deductions  from  established  facts." 
— Homceopathic  Times. 


Cloth,  $1.50. 

' '  The  theory  is  certainly  shown  to  be  a  plausible 
one  ;  and  every  reader,  whether  he  be  convinced  or 
not,  can  not  but  be  interested,  instructed,  and  set  to 
thinking." — Lancet  and  Clinic. 


12 


D.   APPLETON  cS-   CO.'S  MEDICAL    WORKS. 


Specimen  of  Illustration. 


CONTRIBUTIONS  TO  REPARATIVE  SURGERY,  show- 

ing  its  Application  to  the  Treatment  of  Deformities,  produced  by  Destruc- 
tive Disease  or  Injury ;  Congenital  Defects  from  Arrest  or  Excess  of  Devel- 
opment ;  and  Cicatricial  Contractions  following  Burns.    Illustrated  by  Thirty 
Cases  and  fine  Engravings.     By  Gurdon  Buck,  M.  D. 
I  vol.,  8vo,  237  pp.     Cloth,  $3. 

"  There  is  no  department  of  surgery  where  the  ingenuity 
and  skill  of  the  surgeon  are  more  severely  taxed  than  when 
required  to  repair  the  damage  sustained  by  the  loss  of  parts, 
or  to  remove  the  disfigurement  produced  by  destructive  dis- 
ease or  violence,  or  to  remedy  the  deformities  of  congenital 
malformation.  The  results  obtained  in  such  cases  within 
the  last  half-century  are  among  the  most  satisfactory  achieve- 
ments of  modern  surgery.  The  term  '  Reparative  Surgery ' 
chosen  as  the  title  of  this  volume,  though  it  may,  in  a  com- 
prehensive sense,  be  applied  to  the  treatment  of  a  great 
variety  of  lesions  to  which  the  body  is  liable,  is,  however, 
restricted  in  this  work  exclusively  to  what  has  fallen  under 
the  author's  own  observation,  and  has  been  subjected  to  the 
test  of  experience  in  his  own  practice.  It  largely  embraces 
the  treatment  of  lesions  of  the  face,  a  region  in  which  plastic 
surgery  finds  its  most  frequent  and  important  apphcations. 
Another  and  no  less  important  class  of  lesions  will  also  be 
found  to  have  occupied  a  large  share  of  the  author's  atten- 
tion, viz.,  cicatricial  contractions  following  burns.  While 
these  cases  have  a  very  strong  claim  upon  our  commisera- 
tion, and  should  stimulate  us,  as  surgeons,  to  the  greatest 
efforts  for  their  relief,  they  have  too  often  in  the  past  been 
dismissed  as  hopelessly  incurable.  The  satisfactory  results 
obtained  in  the  cases  reported  in  this  volume  will  encour- 
age other  surgeons,  we  trust,  to  resort  with  greater  hope- 
fulness in  the  future  to  operative  interference.  Accuracy 
of  description  and  clearness  of  statement  have  been  aimed 
at  in  the  following  pages ;  and  if,  in  his  endeavor  to  attain 
this  important  end,  the  author  has  incurred  the  reproach  of 
tediousness,  the  difficulty  of  the  task  must  be  his  apology.'^ 
— Extract  from  Preface. 


THE    CHEMISTRY    OF    COMMON    LIFE.      Illustrated 

with  numerous  Wood   Engravings.      By  the  late  James  F.  W.  Johnson, 
F.  R.  S.,   Professor  of  Chemistry  in  the   University  of  Durham.     A  new 
edition,  revised  and  brought  down  to  the  Present  Time.     By  Arthur  Her- 
bert Church,  M.  A.,  Oxon. 
Illustrated  with  Maps  and  numerous  Engravings  on  Wood.     In  one  vol.,  i2mo,  592  pp.     $2. 

SUMMARY  OF  CONTENTS.— The  Mr  wq  Breathe;  the  Water  we  Drink;  the  Soil  we 
Cultivate;  the  Plant  we  Rear;  the  Bread  we  Eat;  the  Beef  we  Cook;  the  Beverages  we  Infuse ; 
the  Sweets  we  Extract ;  the  Liquors  we  Ferment ;  the  Narcotics  we  Indulge  in ;  the  Poisons  we 
Select;  the  Odors  we  Enjoy;  the  Smells  we  Dislike ;  the  Colors  we  Admire ;  What  we  Breathe 
and  Breathe  for;  What,  How,  and  Why  we  Digest;  the  Body  we  Cherish;  the  Circulation  of 
Matter. 

THE   TONIC   TREATMENT   OF    SYPHILIS.     By  E.  L. 

Keyes,  a.  M.,  M.  D.,  Adjunct  Professor  of  Surgery  and  Professor  of  Der- 
matology in  the  Bellevue  Hospital  Medical  College,  etc. 
I  vol.,  8vo,  St,  pp.     Cloth,  $l. 

"  My  studies  in  syphilitic  blood  have  yielded  results  at  once  so  gratifying  to  me,  and  so  con- 
vincing as  to  the  tonic  influence  of  minute  doses  of  mercury,  that  I  feel  impelled  to  lay  this  brief 
treatise  before  the  medical  public  in  support  of  a  continuous  treatment  of  syphilis  by  small  (tonic) 
doses  of  mercury.  I  believe  that  a  general  trial  of  the  method  will,  in  the  long  run,  vindicate  its 
excellence. ' ' — Extract  from  Preface. 


D.   APPLE  TON  &-   CO.'S  MEDICAL    WORKS. 


13 


A    PRACTICAL   TREATISE    ON    TUMORS    OF   THE 

MAMMARY  GLAND:  embracing  their  Histology,  Pathology,  Diagnosis, 
and  Treatment.  By  Samuel  W.  Gross,  A.  M.,  M.  D.,  Surgeon  to,  and 
Lecturer  on  Clinical  Surgery  in,  the  Jefferson  Medical  College  Hospital 
and  the  Philadelphia  Hospital,  etc. 

In  one  handsome  8vo  vol.  of  246  pp.,  with  29  Illustrations.     Cloth,  $2.50. 

"The  work  opportunely  supplies  a  real  want, 
and  is  the  result  of  accurate  work,  and  we  heartily 
recommend  it  to  our  readers  as  well  worthy  of  care- 
ful study." — London  Lancet. 

"  We  know  of  no  book  in  the  Englisli  langfuajje 
which  attempts  to  cover  the  ground  covered  by  tliis 
one — indeed,  the  author  seems  to  be  the  first  who  has 
sought  to  handle  the  whole  subject  of  mammary 
tumors  in  one  systematic  treatise.  How  he  has  suc- 
ceeded will  best  be  seen  by  a  study  of  the  book  itself. 
In  the  early  chapters  the  classification  and  relative 
frequency  of  the  various  tumors,  their  evolution  and 
transformations,  and  their  etiology,  are  dealt  with  ; 
then  each  class  is  studied  in  a  separate  chapter,  in 
which  the  result  of  the  author's  work  is  compared 
with  that  of  others,  and  the  general  conclusions  are 
drawn  which  give  to  the  book  its  great  practical 
value  ;  finally,  a  chapter  is  devoted  to  diagnosis,  one 
to  treatment,  and  one  to  the  tumors  in  the  mam- 
mary gland  of  the  male."  —  New  York  Medical 
Journal. 

' '  We  heartily  commend  tliis  work  to  the  profes- 
sion, knowing  tliat  those  who  study  its  pages  will 
be  well  repaid  and  have  a  better  understanding  of 
what  to  the  average  practitioner  is  obscure  and  un- 
satisfactory."—  Toledo  Medical  and  Surgical  Jour- 
nal. 

"Dr.  Gross  has  produced  a  work  of  real  and 
permanent  value  ;  it  is  not  overstating  the  truth  to 
say  that  this  little  volume  is  probably  the  best  con- 
tribution to  medical  science  which  the  present  year 
has  brought  forth.     We  beUeve  that  the  author  has 


Cystic  Encephaloid  Carcinoma.  ' 

done  what  he  has  set  out  to  do,  viz.,  constructed  r> 
systematic  and  strictly  accurate  treatise  on  mamman 
tumors,  and  brought  to  his  task  all  the  light  afforded 
by  the  most  recent  investigations  into  their  pathol- 
ogy."— .5"^.  Louis  Clinical  Reco7-d. 

"  This  book  is  a  real  contribution  to  our  profes- 
sional literature  ;  and  it  comes  from  a  source  which 
commands  our  respect.  The  plan  is  very  systematic 
and  complete,  and  the  student  or  practitioner  alike 
will  find  exactly  the  information  he  seeks  upon  anj 
of  the  diseases  which  are  incident  to  the  mammar) 
gland." — Obstetrical  Gazette. 

"  Altogether,  the  work  is  one  of  more  than  ordi 
nary  interest  to  the  surgeon,  gynecologist,  and  phy- 
sician."— Detroit  Lancet, 


OUTLINES  OF  THE  PATHOLOGY  AND  TREAT- 
MENT OF  SYPHILIS  AND  ALLIED  VENEREAL  DISEASES.  By 
Hermann  von  Zeissl,  M.  D.,  late  Professor  at  the  Imperial- Royal  Univer- 
sity of  Vienna.  Second  edition,  revised  by  Maximilian  von  Zeissl,  M.  D., 
Privat-Docent  for  Diseases  of  the  Skin  and  Syphilis  at  the  Imperial-Royal 
University  of  Vienna.  Authorized  edition.  Translated,  with  Notes,  by  H. 
Raphael,  M.  D.,  Attending  Physician  for  Diseases  of  the  Genito-Urinary 
Organs  and  Syphilis,  Bellevue  Hospital  Out-patient  Department,  etc. 
8vo,  402  pages.     Cloth,  $4.00;  sheep,  $5.00. 


"  We  regard  the  book  as  an  excellent  text-book 
for  student  or  physician,  and  hope  to  hear  of  its 
adoption  as  sucli  In  therapeutic  detail,  the  rec- 
ommendations are  all  good." — Virginia  Medical 
Monthly. 

"It  is  scarcely  necessary  to  refer  to  the  talented 
author  of  the  above-named  work,  since  his  life-long 
labor  as  a  teacher  and  writer  upon  venereal  diseases 
has  made  him  known  and  quoted  wherever  these  af- 
fections exist  and  are  treated." — Polyclinic. 

"  The  book  is  a  most  excellent  one  in  every  re- 
spect, and  the  translator  has  done  his  work  well." — 
Columbus  Medical  Journal. 

"  It  is  a  most  thorough  and  practical  manual,  and 
translator  and  publisher  both  have  done  well  in  their 
respective  capacities  in  thus  issuing  it." — Medical 
Press  0/  Western  New  York. 


"  Medical  science  suffered  a  severe  loss  when,  in 
September,  1SS4,  Hermann  von  Zeissl  died.  Hap- 
pily for  us,  this  master  in  his  chosen  specialty  had 
embodied  the  results  of  his  vast  experience  in  a  text- 
book on  syphilis  and  venereal  diseases  and  pubhshed 
it  some  years  before  his  death.  The  booli  now  be- 
fore us  is  a  second  edition  of  the  former  book,  re- 
vised and  in  large  part  rewritten  by  Maximilian  von 
Zeissl,  and  issued  in  the  original  some  seven  months 
before  the  father's  death.  It  is  a  masterly  treatise 
and  thoroughly  practical.  We  can  commend  it  to 
all  who  are  interested  in  venereal  subjects.  .  .  .  Dr. 
Raphael  has  made  a  smooth  and  readable  transla- 
tion and  has  added  much  valuable  matter  to  the  book, 
adapting  it  to  the  use  of  American  physicians.  The 
chapter  on  galloping  syphilis  is  entirely  by  him." — 
The  New  York  Medical  Journal. 


H 


D.  APPLE  TON  &-   CO:S  MEDICAL    WORKS. 


EMERGENCIES,     AND     HOW     TO     TREAT     THEM. 

The  Etiology,  Pathology,  and  Treatment  of  Accidents,  Diseases,  and  Cases 
of  Poisoning,  which  demand  Prompt  Action.  Designed  for  Students  and 
Practitioners  of  Medicine.  By  Joseph  W.  Howe,  M.  D.,  Clinical  Profess- 
or of  Surgery  in  the  Medical  Department  of  the  University  of  New  York, 
etc.,  etc. 

Fourth  edition,  revised,     i  vol.,  8vo,  265  pp.     Cloth,  $2.50. 

book  we  recommend  it  most  heartily  to  the  profes- 
sion."— Boston  Medical  and  Surgical  Journal. 

' '  This  work  bears  evidence  of  a  thoroug-h  prac- 
tical acquaintance  with  the  different  branches  of  the 


"  To  the  general  practitioner  in  towns,  villages, 
and  in  the  countrj-,  where  the  aid  and  moral  sup- 
port of  a  consultation  can  not  be  availed  of,  this 
volume  will  be  recognized  as  a  valuable  help.  We 
commend  it  to  the  profession." — Ci7icinnati Lancet 
arid  Observer. 

"  The  author  wastes  no  words,  but  devotes  him- 
self to  the  description  of  each  disease  as  if  the  pa- 
tient were  under  his  hands.     Because  it  is  a  good 


profession.  The  author  seems  to  possess  a  peculiar 
aptitude  for  imparting  instruction  as  well  as  for 
simplifying  tedious  details.  A  careful  perusal  will 
amply  repay  the  student  and  practitioner." — New 
York  Medical  Joiirjial. 


Specimen  of  Illustration. 


A  TREATISE  ON  THE  DISEASES  OF  THE  NERV- 
OUS SYSTEM.  By  William  A.  Hammond,  M.  D.,  Surgeon-General 
U.  S.  Army  (retired  list)  ;  Professor  of  Diseases  of  the  Mind  and  Nervous 
System  in  the  New  York  Post-Graduate  Medical  School  and  Hospital; 
Member  of  the  American  Neurological  Association  and  of  the  New  York 
Neurological  Society ;  of  the  New  York  County  Medical  Society,  etc. 

With  112  Illustrations.  Eighth 
edition,  revised,  corrected, 
and  enlarged  by  the  Addi- 
tion of  a  New  Section  on 
Certain  Obscure  Nervous 
Diseases.  8vo,  945  pages. 
Cloth,  $5.00;  sheep,  $6.00. 

The  work  has  received  the 
honor  of  a  French  translation 
by  Dr.  Labadie-Lagrave,  of 
Paris,  and  an  Italian  transla- 
tion by  Professor  Diodato  Bor- 
relli,  of  the  Royal  University, 
has  gone  through  the  press  at 
Naples. 

"  In  the  Buddhist  faith  the 
eight  gates  of  purity  are  de- 
scribed as :  I.  Correct  ideas  ;  2. 
Correct  thoughts ;  3.  Correct 
words ;  4.  Correct  works ;  5. 
Correct  life  ;  6.  Correct  endeav- 
ors ;  7.  Correct  judgment ;  and 
8.  Correct  tranquillity.  If  Dr. 
Hammond  has  not  attained  the  medical  nirvana,  and  passed  those  eight  gates  of  purity,  he  has  at  least 
realized  the  Buddhist  beatitude  :  '  Much  insight  and  education,  self-control  and  pleasant  speech ;  and 
whatever  word  be  well  spoken,  this  is  the  greatest  blessing.'  At  least,  the  thoughts  and  utterances  of  Dr. 
Hammond  have  been  so  appreciated  by  the  medical  profession  of  America  and  England  that  the  work  has 
already  passed  through  eight  editions  since  its  first  appearance  in  1871.  As  now  revised  by  the  author 
and  published  by  the  Appletons,  it  constitutes  decidedly  the  best  work  in  the  English  language  upon  dis- 
eases of  the  nervous  system." — Kansas  City  Medical  Index. 

ten  anything  but  this  one  work,  it  would  have  been 
a  monument  of  learning  that  would  have  lasted  for 
ages." — Kansas  City  Medical  Record. 


"  This  excellent  work  has  now  been  fifteen  years 
before  the  profession,  its  popularity  being  sufficient- 
ly evidenced  by  the  fact  that  it  has  rapidly  passed 
through  eight  editions.'' — College  and  Clinical  Rec- 
ord. 


"This  great  work  of  the  gifted  author  has  now 
reached  its  eighth  edition.  A  work  of  this  charac- 
ter that  has,  within  fifteen  years,  gone  through  eight 
revisions  needs  but  little  commendation  from  us, 
being  fully  able  to  speak  for  itself.  It  is,  like  its  au- 
thor, without  a  peer  in  the  special  line  of  medicine 
it  takes  up.  ...  If  Dr.  Hammond  had  never  writ- 


"  The  author  of  this  work  justly  congratulates 
himself  that  the  various  previous  editions  which 
have  been  called  for  have  received  the  approval  of 
the  profession  beyond  that  ever  given  to  any  other 
work  of  like  scope  and  objects  published  in  any  part 
of  the  world.  In  order  to  maintain  the  high  char- 
acter thus  attributed  to  it  by  the  best  judges,  he  has 
subjected  this  edition  to  a  thorough  revision,  and  has 
added  a  new  section  treating  of  certain  obscure  dis 


D.  APPLETON  &-   CO:S  MEDICAL    WORKS. 


15 


eases  ot  the  nervous  system,  as  tetany,  Thomsen's 
disease,  miryachit,  and  kindred  affections.  In  all 
respects  we  must  place  this  treatise  as  the  best  in  the 
langfuage  on  the  specialty  to  which  it  is  devoted." — 
.Medical  and  Surgical  Reporter. 

"When  a  work  has  reached  its  eighth  edition, 
the  reviewer  might  as  well  keep  quiet,  as  the  book- 
buyer  has  already  decided  that  a  demand  has  been 
met." — A'eiu  YorA  Medical  Tijiies. 

"  This  volume  has  been  received  by  the  profes- 
sion '  to  an  extent  beyond  that  ever  given  to  any 
other  work  of  like  scope  and  objects  published  in  any 
part  of  the  world.'  The  present  edition  contains  a 
section  on  '  Certain  Obscure  Diseases  of  the  Nervous 
System,'  is  thoroughly  revised  throughout,  and  sev- 
eral changes  made,  thereby  increasing  greatly  its  use- 
fulness."— Buffalo  Medical  a?id  Surgical  Jourtial. 

' '  The  eighth  edition  of  this  work  speaks  for  itself 
in  the  fact  of  its  existence.  The  talented  author 
has  carefully  revised  the  previous  editions,  elaborat- 
ing many  portions  which  subsequent  experience  and 
observation  have  made  necessary.  A  section  has 
also  been  added  on  certain  obscure  diseases  of  the 
nervous  system,  comprising  tetany,  Thomsen's  dis- 
ease, miryachit,  and  kindred  affections.  These  sub- 
jects are  treated,  like  others  in  the  work,  with  a 
master-hand  and  with  the  pen  of  a  ready  and  enter- 
taining writer.  The  author  made  his  reputation  long 
ago,  and  that  he  is  able  to  maintain  it  his  last  effort 
will  abundantly  prove." — Medical  Record. 


Specimen  of  Illustration. 


%,!^'^'^^' 


CLINICAL     LECTURES     ON     DISEASES     OF     THE 

NERVOUS    SYSTEM.     Delivered  at  the  Bellevue  Hospital  Medical  Col- 
lege.    By  William  A.  Hammond,  M.  D.,  Professor  of  Diseases  of  the  Mind 
and  Nervous  System,  etc.     Edited,  with  Notes,  by  T.  M.  B.  Cross,  M.  D., 
Assistant  to  the  Chairs  of  Diseases  of  the  Mind  and  Nervous  System,  etc. 
In  one  handsome  vohime  of  300  pages.     $3.50. 

These  lectures  have  been  reported  in  full,  and,  together  with  the  histories  of  the  cases,  which 
were  prepared  by  the  editor  after  careful  study  and  prolonged  observation,  constitute  a  clinical 
volume  which,  while  it  does  not  claim  to  be  exhaustive,  will  nevertheless  be  found  to  contain 
many  of  the  more  important  affections  of  the  kind  that  are  commonly  met  with  in  practice. 

As  these  lectures  were  intended  especially  for  the  benefit  of  students,  the  author  has  confined 
himself  to  a  full  consideration  of  the  symptoms,  causes,  and  treatment  of  each  affection,  without 
attempting  to  enter  into  the  pathology  or  morbid  anatomy. 


THE    ANATOMY     OF    VERTEBRATED     ANIMALS. 

By  Thomas  Henry  Huxley,  LL.  D.,  F.  R.  S. 

I  vol.,  i2mo.     Illustrated.     431  pp.     Cloth,  $2.50. 

"  The  present  work  is  intended  to  provide  students  of  comparative  anatomy  with  a  condensed 
statement  of  the  most  important  facts  relating  to  the  structure  of  vertebrated  animals  which  have 
hitherto  been  ascertained.  The  Vertebrata  are  distinguished  from  all  other  animals  by  the  circum- 
stance that  a  transverse  and  vertical  section  of  the  body  exhibits  two  cavities  completely  separated 
from  one  another  by  a  partition.  The  dorsal  cavity  contains  the  cerebro-spinal  nervous  system  ; 
the  ventral,  the  alimentary  canal,  the  heart,  and  usually  a  double  chain  of  ganglia,  which  passes 
under  the  name  of  the  '  sympathetic. '  It  is  probable  that  this  sympathetic  nervous  system  repre- 
sents, wholly  or  partially,  the  principal  nervous  system  of  the  Animlosa  and  Mollusca.  And,  in 
any  case,  the  central  parts  of  the  cerebro-spinal  nervous  system,  viz.,  the  brain  and  the  spinal 
cord,  would  appear  to  be  unrepresented  among  invertebrated  animals." — The  Author. 

"  This  long-expected  work  will  be  cordially  wel-  It  is  enough  to  say  that  it  realizes,  in  a  remarkable 

comed  by  all  students  and  teachers  of  Comparative  deg^ree,  the  anticipations  which  have  been  formed 

Anatomy  as  a  compendious,  reliable,  and,  notwith-  of  it ;  and  that  it  presents  an  extraordinary  combi- 

standing  its  small  dimensions,  most  comprehensive  nation  of  wide,  general  views,  with  the  clear,  accu- 

guide  on  the  subject  of  which  it  treats.     To  praise  rate,  and  succinct  statement  of  a  prodigious  number 

or  to  criticise  the  work  of  so  accomplished  a  master  of  individual  facts." — Nature. 
of  his  favorite  science  would  be  equally  out  of  place. 


i6 


D.   APPLETON  6-   CO.'S  MEDICAL    WORKS. 


Specimen  of  Illustration. 


A   TREATISE   ON    ORAL   DEFORMITIES,  as  a  Branch 

of  Mechanical  Surgery.  By  Norman  W.  Kingsley,  M.  D.  S.,  D.  D.  S., 
President  of  the  Board  of  Censors  of  the  State  of  New  York,  late  Dean  of 
the  New  York  College  of  Dentistry  and  Professor  of  Dental  Art  and  Mech- 
anism, etc.,  etc. 

With  over  350  Illustrations.     One  vol.,  8vo.     Cloth,  $5;  sheep,  $6. 

"  I  have  read  with  great  pleasure  and  much 
profit  your  valuable  '  Treatise  on  Oral  Deformi- 
ties.' The  v^'ork  contains  much  original  matter 
of  great  practical  value,  and  is  full  of  useful  in- 
formation, which  will  be  of  great  benefit  to  the 
profession." — Lewis  A.  Sayre,  M.  D.,  LL.  D., 
Professor  of  Orthopedic  Siirgery  and  Clinica! 
Surge?'y,  Bellevue  flospital  Medical  College. 

"A  casual  glance  at  this  work  might  impress 
the  reader  with  the  idea  that  its  contents  were  of 
more  practical  value  to  the  dentist  than  to  the 
general  practitioner  or  surgeon.  But  it  is  by  no 
means  a  mere  work  on  dentistry,  although  a  prac- 
tical knowledge  of  the  latter  art  seems  to  be  es- 
sential to  the  carrying  out  of  the  author's  views 
regarding  the  correction  of  the  different  varieties 
of  oral  deformities  of  which  he  treats.  We  would 
be  doing  injustice  to  the  work  did  not  we  make 
particular  reference  to  the  masterly  chapter  on  the 
treatment  of  fractures  of  the  lower  jaw.  The 
whole  subject  is  so  thoroughly  studied  that  noth- 
ing is  left  to  be  desired  by  any  surgeon  who  wish- 
es to  treat  these  fractures  intelligently  and  success- 
fully. The  work,  as  a  whole,  bears  marks  of 
originality  in  every  section,  and  impresses  the 
reader  with  the  painstaking  efforts  of  the  author 
to  get  at  the  truth,  and  apply  it  in  an  ingenious 
and  practical  way  to  the  wants  of  the  general 
practitioner,  the  surgeon,  and  the  dentist." — 
Medical  Record. 

"The  profession  is  to  be  congratulated  on 
possessing  so  valuable  an  addition  to  its  litera- 
ture and  the  author  to  be  unstintedly  praised  for  his  successful  issue  to  an  arduous  undertaking.  The  work 
bears   in  a  word,  every  evidence  of  having  been  written  leisurely  and  with  care.  .   .   ."—Dental  Cosmos. 

"To  the  surgeon  and  general  practitioner  of  medicine,  as  well  as  the  dentist,  its  mstruction  will  be 

found  invaluable.     It  is  clear  in  style,  practical  in  its  application,  comprehensive  in  its  illustrations,  and  so 

exhaustive  that  it  is  not  likely  to  meet  in  these  respects  a  rival."-WiLLiAM  H.  Dwinelle,  A.  M.,  M.  D. 

"  I  consider  it  to  be  the  most  valuable  work  that  has  ever  appeared  in  this  country  in  any  department 

of  the  science  of  dental  surgery.  .  ,        ,       .   j         j  ^-      *u-    u        i, 

"There  is  no  doubt  of  its  great  value  to  every  man  who  wishes  to  study  and  practice  this  branch 

of  surgery,  and  I  hope  it  may  be  adopted  as  a  text-book  in  every  dental  college,  that  the  students  may 

have  the  benefit  of  the  great  experience  of  the 

author. 

"  It  places  many  things  between  the  covers  of 

one  book  which  heretofore  I  have  been  obliged  to 

look  for  in  many  directions,  and  often  without 

success."— Frank   Abkot,   M.  D.,  Dean  of  the 

New  York  College  of  Dentistry. 

' '  The  writer  does  not  hesitate  to  express  his 

belief  that  the  chapters  on  the  '  aesthetics  of  den- 
tistry '  will  be  found  of  more  practical  value  to 

tlie  prosthetic  dentist  than  all  the  other  essays 

on  this  subject  existent  in  the  English  language. 

...  A  perusal  of  its  pages  seems  to  compel  the 

mind  to  advance  in  directions  variously  indi- 
cated ;  so  variously,  indeed,  that  there  is  hardly 

a  page  of  the  book  which  does  not  contain  some 

important  truth,  some  pregnant  hint,  or  some  ^ 

valuable  conclusion." — Dental  Afiscellany. 

"I   congratulate   you    on   having  written   a 

book  containing  so  much  valuable  and  original 
matter.  It  will  prove  of  value  not  only  to  den- 
tists, but  also  to  surgeons  and  physicians." — 
Frank  Hastings  Ha.milton,  M.  D.,  LL.  D., 
Ptofessor  of  the  Practice  of  Surgery  with  Opera- 
tions, and  of  Clinical  Surgery  in  Bellevue  Hos- 
pital Medical  College. 


Specimen  of  Illustration. 


D.   APPLE  TON  &^   CO.'S  MEDICAL    WORKS. 


17 


THE  BREATH,  AND  THE  DISEASES  WHICH  GIVE 

IT  A  FETID  ODOR.  With  Directions  for  Treatment.  By  Joseph  VV. 
Howe,  M.  D.,  Clinical  Professor  of  Surgery  in  the  Medical  Department  of 
the  University  of  New  York,  etc. 

Second  edition,  revised  and  corrected,     i  vol.,  i2mo,  108  pp.     Cloth,  $1. 

"  This  little  volume  well  deserves  the  attention 
of  physicians,  to  whom  we  commend  it  most  high- 
ly."— Chicago  Medical  JoJirnal. 

"  To  any  one  suffering  from  the  affection,  either 
in  his  own  person  or  in  that  of  his  intimate  ac- 
quaintances, we  can  commend  this  volume  as  con- 
taining all  that  is  known  concerning  the  subject,  set 


forth  in  a  pleasant  style." — Fhiladelphia  Medical 
Times. 

"  The  author  gives  a  succinct  account  of  the  dis- 
eased conditions  in  which  a  fetid  breath  is  an  im- 
portant symptom,  with  his  method  of  treatment. 
We  consider  the  work  a  real  addiiion  to  medical  lit- 
erature."— Cincinnati  Medical  Journal. 


ON  THE  BILE,  JAUNDICE,  AND  BILIOUS  DIS- 
EASES. By  J.  WiCKHAM  Legg,  M.  D.,  F.  R.  C.  S.,  Assistant  Physician  to 
St.  Bartholomew's  Hospital,  and  Lecturer  on  Pathological  Anatomy  in  the 
Medical  School. 

In  one  volume,  8vo,  719  pp.     With  Illustrations  in  Chromo-lithography.      Cloth,  $6 ;  sheep,  $7. 


"...  And  let  us  turn — which  we  gladly  do — to 
the  mine  of  wealth  which  the  volume  itself  contains, 
for  it  is  the  outcome  of  a  vast  deal  of  labor  ;  so 
great  indeed,  that  one  unfamiliar  with  it  would  be 
surprised  at  the  nuniber  of  facts  and  references 
which  the  book  contains." — Medical  Times  and  Ga- 
zefti',  Londoji. 

"  The  book  is  an  exceedingly  good  one,  and,  in 
some  points,  we  doubt  if  it  could  be  made  better. 
.  .  .  And  we  venture  to  say,  after  an  attentive 
perusal  of  the  whole,  that  any  one  who  takes  it 
in  hand  will  derive  from  it  both  information  and 
pleasure  ;  it  gives  such  ample  evidence  of  honest 
hard  work,  of  wide  reading,  and  an  impartial  at- 
tempt to  state  the  case  of  jaundice,  as  it  is  known 
by  observation  up  to  the  present  date.  The  book 
will  not  only  live,  but  be  in  the  enjoyment  of  a  vig- 
orous existence  long  after  some  of  the  more  popular 
productions  of  the  present  age  are  buried,  past  all 
hope  of  resurrection." — London  Medical  Reco7-d. 

"  This  portly,  tome  contains  the  fullest  account 
of  the  subjects  of  which  it  treats  in  the  English. lan- 
guage. The  historical,  scientific,  and  practical  de- 
tails are  all  equally  well  worked  out,  and  together 
constitute  a  repertorium  of  knowledge  which  no 
practitioner  can  well  dn  without.  The  illustrative 
chromo-lithographs  are  beyond  all  praise." — Edi?i- 
burgli  Medical  'Journal. 


' '  Dr.  Legg's  treatise  is  a  really  great  book,  ex- 
hibiting immense  industry  and  research,  and  full  of 
valuable  information." — American  Journal  of  Med- 
ical Scietice. 

' '  It  seems  to  us  an  exhaustive  epitome  of  all 
that  is  known  on  the  subject." — Fhiladelphia  Medi- 
cal Titnes. 

"This  volume  is  one  which  will  command  pro- 
fessional respect  and  attention.  It  is,  perhaps,  the 
most  comprehensive  and  exhaustive  treatise  upon 
the  subject  treated  ever  published  in  the  English 
language." — Maj-yland  Medical  Jour7ial. 

"  It  is  the  work  of  one  who  has  thoroughly  stud- 
ied the  subject,  and  who,  when  he  finds  the  evi- 
dence conflicting  on  disputed  points,  has  attempted 
to  solve  the  problem  by  experiments  and  observa- 
tions of  his  own." — Practitioner,  London. 

"It  is  a  valuable  work  of  reference  and  a  wel- 
come addition  to  medical  literature. — Dublin  Jour- 
nal of  Medical  Science. 

"...  The  reader  is  at  once  struck  with  the  im- 
mense amount  of  research  exhibited,  the  author 
having  left  unimproved  no  accessible  source  of  in- 
formation connected  with  his  subject.  It  is,  indeed, 
a  valuable  book,  and  the  best  storehouse  of  knowl- 
edge in  its  department  that  we  know  of." — Pacific 
Medical  a7id  Surgical  Jourtial. 


FIRST    LINES    OF    THERAPEUTICS    as    Based   on    the 

Modes  and  the  Processes  of  Healing,  as  occurring  spontaneously  in  Dis- 
eases ;  and  on  the  Modes  and  the  Processes  of  Dying  as  resulting  naturally 
from  Disease.  In  a  Series  of  Lectures.  By  Alexander  Harvey,  M.  A., 
M.  D.,  Emeritus  Professor  of  Materia  Medica  in  the  University  of  Aber- 
deen, etc.,  etc. 

I  vol.,  i2mo,  278  pp.      Cloth,  $1.50. 


"  If  only  it  can  get  a  fair  hearing  before  the  pro- 
fession it  will  be  the  means  of  aiding  in  the  devel- 
opment of  a  therapeutics  more  rational  than  we 
now  dream  of.  To  medical  students  and  practi- 
tioners of  all  sorts  it  will  open  up  lines  of  thought 
and  investigation  of  the  utmost  moment." — Detroit 
Lancet. 

2 


"We  may  say  that,  as  a  contribution  to  the 
philosophy  of  medicine,  this  treatise,  which  may  be 
profitably  read  during  odd  moments  of  leisure,  has 
a  happy  method  of  statement  and  a  refreshing  free- 
dom from  dogmatism." — JVew  York  Medical  Rec- 
ord. 


i: 


D.   APPLE  TON  &-   CO:S  MEDICAL    WORKS. 


THE     SCIENCE    AND    ART     OF     MIDWIFERY.      By 

William  Thompson  Lusk,  M.  A.,  M.  D.,  Professor  of  Obstetrics  and  Dis- 
eases of  Women  and  Children  in  the  Bellevue  Hospital  Medical  College  ; 
Obstetric  Surgeon  to  the  Maternity  and  Emergency  Hospitals ;  and  Gynae- 
cologist to  the  Bellevue  Hospital. 

New  edition.     Revised  and  enlarged.     Complete  in  one  volume,  8vo,  with  246  Illustrations. 

Cloth,  $5.00;  sheep,  $6.00.  .  j^  ^^^^^j^g  ^^^  ^f  ^^^  ^^^^  ^^^ 

.  positions  of  the  obstetric  science  and 
practice  of  the  day  with  which  we 
are  acquainted.  Throughout  the 
work  the  author  shows  an  intimate 
acquaintance  with  the  hterature  of 
obstetrics,  and  gives  evidence  of  large 
practical  experience,  great  discrimi- 
nation, and  sound  judgment.  We 
heartily  recommend  the  book  as  a 
full  and  clear  exposition  of  obstetric 
science  and  safe  guide  to  student  and 
practitioner." — London  Lancet. 

"  Professor  Lusk's  book  presents 
the  art  of  midwifery  with  all  that 
modern  science  or  earlier  learning 
has  contributed  to  it." — Medical 
Reco7'd,  New  York. 

"This  book  bears  evidence  on 
every  page  of  being  the  result  of 
patient  and  laborious  research  and 
great  personal  experience,  united 
and  harmonized  by  the  true  critical 
or  scientific  spirit,  and  we  are  con- 
vinced that  the  book  will  raise  the 
general  standard  of  obstetric  knowl- 
edge both  in  his  own  country  and 
in  this.  Whether  for  the  student  obliged  to  learn  the  theoretical  part  of  midwifery,  or  for  the  busy  prac- 
titioner seeking  aid  in  face  of  practical  difficulties,  it  is,  in  our  opinion,  the  best  modern  work  on  mid- 
wifery in  the  English  language." — Dublm  Journal  of  Medical  Scie7ice. 


D'Outrepont's  Method,  modified  by  Scanzoni. 


Author's  Modification  of  Tarnier's  Forceps. 


"  Dr.  Lusk's  style  is  clear,  generally  concise,  and 
he  has  succeeded  in  putting  in  less  than  seven  hun- 
dred pages  the  best  exposition  in  the  English  lan- 
guage of  obstetric  science  and  art.  The  book  will 
prove  invaluable  alike  to  the  student  and  the  prac- 
titioner."— Ame7-ican  Practitioner'. 

"  Dr.  Lusk's  work  is  so  comprehensive  in  design 
and  so  elaborate  in  execution  that  it  must  be  recog- 
nized as  having  a  status  peculiarly  its  own  among 
the  text-books  of  midwifery  in  the  English  lan- 
guage."— New  York  Mediccil  Journal. 

"The  work  is,  perhaps,  better  adapted  to  the 
wants  of  the  student  as  a  text-book,  and  to  the 
practitioner  as  a  work  of  reference,  than  any  other 
one  publication  on  the  subject.  It  contains  about 
all  that  is  known  of  the  ars  ohstetrica,  and  must 
add  greatly  to  both  the  fame  and  fortune  of  the 
distinguished  author." — Medical  Herald,  Lotiis- 
villc. 


"Dr.  Lusk's  book  is  eminently  viable.  It  can 
not  fail  to  live  and  obtain  the  honor  of  a  second,  a 
third,  and  nobody  can  foretell  how  many  editions. 
It  is  the  mature  product  of  great  industiy  and  acute 
observation.  It  is  by  far  the  most  learned  and  most 
complete  exposition  of  the  science  and  art  of  obstet- 
rics written  in  the  English  language.  It  is  a  book 
so  rich  in  scientific  ancl  practical  information,  that 
nobody  practicing  obstetrics  ought  to  deprive  him- 
self of  the  advantage  lie  is  sure  to  gain  from  a  fre- 
quent recourse  to  its  pages." — American  Journal oj 
Obstetrics. 

"It  is  a  pleasure  to  read  such  a  book  as  that 
which  Dr.  Lusk  has  prepared  ;  everything  pertain- 
ing to  the  important  subject  of  obstetrics  is  dis- 
cussed in  a  masterly  and  captivating  manner.  We 
recommend  the  book  as  an  excellent  one,  and  feel 
confident  that  those  who  read  it  will  be  amply  re- 
paid."— Obstetric  Gazette,  Cinciiinati. 


D.  APPLETON  &-  CO.'S  MEDICAL  WORKS.  I9 

THE  METHODS  OF  BACTERIOLOGICAL  INVESTI- 
GATION. By  Ferdinand  Hueppe,  Decent  in  Hygiene  and  Bacteriology 
in  the  Chemical  Laboratory  of  R.  Fresenius,  at  Wiesbaden.  Written  at  the 
request  of  Dr.  Robert  Koch.  Translated  by  Hermann  M.  Biggs,  M.  D., 
Instructor  in  the  Carnegie  Laboratory,  and  Assistant  to  the  Chair  of  Patho- 
logical Anatomy  in  Bellevue  Hospital  Medical  College. 
8vo,  218  pp.     With  31  Illustrations.     Cloth,  $2.50. 

'  ■  This  is  the  best  book  so  far  available  in  Eng-  of  author,  and  is  one  which  no  student  of  pathol- 

lish,  being  better  adapted  to  the  general  student  who  ogy   can   afford   to   be   without.     The   translation 

undertakes  the  study  from  first  principles." — North  seems  to  have  been  most  acceptably  made."  —Medi- 

Carolina  Medical  Joui-nal.  cal  Press  of  Western  New  York. 

"  All  students  of  bacteriology  will  at  once  place  u  Qf  the  many  works  that  have  recently  appeared 

this  volume  on  their  tables  as  mdispensable  for  their  ^^  ^^^  g^bject  of  bacterial  technology,  this  one  cer- 

most  accurate  and  rapid  study.  —American  Lancet,  ^^j^iy  ^^^^^  ^he  requirements  of  a  practical  guide 

"The  work  is  written  by  one  who  thoroughly  and  book  of  reference  ;  .  .   .  the  merits  of  the  work 

understands  his  subject  and  puts  it  clearly  before  the  are  decided,  and  should  secure  for  it  the  reputation 

stnd&ni."— Pacific  Medical  and  Surgical  Joiirnal  it     deserves:' —Atlanta     Medical    and    Su7-gical 

and  Western  Lancet.  Jom-nal. 

"He  has  sifted  the  whole  of  the  scattered  and  "The  book  treats  the  subject  in  an  exceedingly 

sometimes  almost  inaccessible  literature  of  the  sub-  clear  and  comprehensive  manner,  and  leaves  httle  to 

ject,  and  has  furnished  the  independent  investigator  ^g  desired  by  the  beginner,  and  is  a  complete  guide 

a  most  valuable  book,  useful  alike  to  the  practitioner  to  those  wishing  to  work  out  any  of  the  innumerable 

and  to  the  student,  as  a  trustworthy  introduction  problems   connected   with    the'  Hfe-history   of    the 

into  this  territory."— C(3//^^<?  and  Clinical  Reco7-d.  bacteria.  .   .  .    The   translation   seems   to  be   well 

"  To  those  who  wish  to  have  more  than  a  mere  doue.''-American  Journal  0/ the  Medical  Sciences. 
theoretical   knowledge    of  the  subject   the  manual  "  The  imnortance  of  this  subiect  in  the  scientific 

will  be  found  indispensable. "—Medical  Record.  J  ^^      'I     ih  -^^,,.1  f^rc^^t.V.H.^i^f  r^^cl^ 

^  world  .  .  .  should  insure  tor  so  practical  a  presen- 

"As  a  whole,  the  book,  written  at  Professor  tation  of  it  as  is  found  in  the  present  volume  a  wide 
Koch's  request,  reflects  credit  on  the  master's  choice     popularity." — New  England  Medical  Gazette. 

HEALTH  PRIMERS.  Edited  by  J.  Langdon  Down,  M.  D., 
F.  R.  C.  P. ;  Henry  Power,  M.  B.,  F.  R.  C.  S.  ;  J.  Mortimer-Granville, 
M.  D.  ;  John  Tweedy,  F.  R.  C.  S. 

In  square  l6mo  volumes.     Cloth,  40  cents  each. 

Though  it  is  of  the  greatest  importance  that  books  upon  health  should  be  in  the  highest  degree 
trustworthy,  it  is  notorious  that  most  of  the  cheap  and  popular  kind  are  mere  crude  compilations 
of  incompetent  persons,  and  are  often  misleading  and  injurious.  Impressed  by  these  considera- 
tions, several  eminent  medical  and  scientific  men  of  London  have  combined  to  prepare  a  series  of 
Health  Primers  of  a  character  that  shall  be  entitled  to  the  fullest  confidence.  They  are  to  be 
brief,  simple,  and  elementary  in  statement,  filled  with  substantial  and  useful  information  suitable 
for  the  guidance  of  grown-up  people.  Each  primer  will  be  written  by  a  gentleman  specially  com- 
petent to  treat  his  subject,  while  the  critical  supervision  of  the  books  is  in  the  hands  of  a  commit- 
tee who  will  act  as  editors. 

As  these  little  books  are  produced  by  English  authors,  they  are  naturally  based  very  much 
upon  English  experience,  but  it  matters  little  whence  illustrations  upon  such  subjects  are  drawn, 
because  the  essential  conditions  of  avoiding  disease  and  preserving  health  are  to  a  great  degree 
everywhere  the  same. 

Volumes  naw  I'eady. 
I.  Exercise  and  Training. 
II.  Alcohol  :   its  Use  and  Abuse. 

III.  Premature  Death  :  its  Promotion  and  Prevention, 

IV.  The  House  and  its  Surroundings. 

V.  Personal  Appearance  in  Health  and  Disease. 
VI.  Baths  and  Bathing. 
VII.  The  Skin  and  its  Troubles. 
VIII.  The  Heart  and  its  Functions. 
IX.  The  Nervous  System. 


20  D.  APPLE  TON  &-  CO.'S  MEDICAL   WORKS. 

ANALYSIS    OF   THE    URINE,  with  Special    Reference  to 

the  Diseases  of  the  Genito-Urinary  Organs.  By  K.  B.  Hofmann,  Pro- 
fessor in  the  University  of  Gratz,  and  R.  Ultzmann,  Decent  in  the  Uni- 
versity of  Vienna.  Translated  by  T.  Barton  Brune,  A.  M.,  M.  D.,  late 
Professor  of  the  Practice  of  Medicine  in  the  Baltimore  Polyclinic  and  Post- 
Graduate  Medical  School,  etc.,  and  H.  Holbrook  Curtis,  Ph.  B.,  M.  D., 
Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
Second  edition,  revised  and  enlarged.     With  8  Lithographic  Plates.     8vo,  310  pp.     Cloth,  $2.00. 

"  Hofmann  and   Ultzmann's  popular  work  on  latest  advances  in  urinary  analysis.    All  unnecessary 

the  urine  needs  neither  criticism  nor  recommenda-  matter  has  been  eliminated,  and  the  chemistry  is  so 

tion.     Its   claims  have  been   substantiated   in  the  simple  as  to  be  within  the  comprehension  of  all. 

offices  of  thousands  of  physicians  both  in  Europe  The  translators  have  made  a  few  additions  which 

and  America.     It  covers  the  entire  field  of  chemical  are  practical  and  therefore  useful." — Canada  Lan- 

and  microscopical  examination  of  urine  so  far  as  cet. 

diagnosis  is  concerned,  giving  explicit  directions  as  ,  ™,  .                               ,                 j     j        1.     • 

to  details  of  raz.-amv\3.Woxi:'—Hah7ie7nannian.  This  work  has  long  been  standard  authority. 

But  the  late  advances  m  urmology  have  made  it  ne- 

"  Possessed  of  this  book,  a  few  reagents,  a  mi-  cessary  for  the  American  translators  practically  to 

croscope  with  glasses  powerful  enough  to  magnify  become  editors  of  a  new  or  second  edition.     They 

two  or  three   hundred  diameters,  and  a  few  test-  have  done  their  work  well,  and  in  this  volume  pre- 

tubes  and  slides,  there  is  no  good  reason  why  every  sent  the  profession  with  a  reliable,  practical  book, 

physician  should  not  become  a  good  urinary  ana-  giving  the  most  advanced  ideas  as  to  urinalysis  and 

lyst." — Mississippi  Valley  Medical  Monthly.  diagnosis  of  urinary  troubles  in  simple  language, 

,,T^      ,,                 J              i      r  ii.             -i-  which  does  not  require  a  mastery  of  clinical  tech- 

"For  the  every-day  wants  of  the  practitioner,  we  ^o\o^^ounA^xst^lA:^-VirginiI Medical  Monthly. 

know  of  no  manual  on  urinary  analysis  that  equals  ^■'                                      * 

Hofmann  and  Ultzmann's  work.  .  .  .  The  second  "  In  the  present  edition  all  unnecessary  matter 

edition  contains  all   the  important   advances  that  has  been  eliminated,  and  the  translators  have  incor- 

have  been  made  in  the  examination  of  the  urinary  porated   all   that   has  recently  been  added  to  our 

constituents  during  the   past  three  years.     One  of  knowledge  of  the  subject  that  will  be  of  especial  in- 

the  most  important  sections  of  the  work  is  that  de-  terest  to  the  student  and  practitioner.     A  valuable 

voted  to  an  account  of  the  microscopical  and  clinical  feature  of  the  book   is  the  illustrations,  which  are 

aids  for  the  diagnosis  of  the  different  forms  of  albu-  very  fine  indeed." — India?ia  Medical  Journal. 

minuria.     The  translators  are  to  be  congratulated  ,,r.     ,              ,              ,           ...•                      1 

on  producing  a  very  clear  and  readable  rendering  of  ,        Students  and  general  practitioners  can  ask  no 

the    original. "-Ca«a</«    Medical    a7id    Surgical  better  working  guide  on  the  subjects  treated   than 

'journal  '^  standard  work.     The  publishers  present  it  m  a 

'  handsome  and  durable  form,  and  the  colored  plates 

"The  second  edition  of  this  classical  work  on  are  uncommonly  finished  and  fine." — Neiv  England 

the  urine  will  be  welcomed  as  containing  all   the  Medical  Gazette. 

CLINICAL    ELECTRO-THERAPEUTICS.     (Medical  and 

Surgical.)  A  Manual  for  Physicians  for  the  Treatment  more  especially  of 
Nervous  Diseases.  By  Allan  McLane  Hamilton,  M.  D.,  Physician  in 
charge  of  the  New  York  State  Hospital  for  Diseases  of  the  Nervous  System, 
etc.,  etc. 

With  numerous  Illustrations.      I  vol.,  Svo.     Cloth,  $2. 

This  work  is  the  compilation  of  well-tried  measures  and  reported  cases,  and  is  intended  as  a 
simple  guide  for  the  general  practitioner.  It  is  as  free  from  confusing  theories,  technical  terms, 
and  unproved  statements  as  possible.  Electricity  is  indorsed  as  a  very  valuable  remedy  in  certain 
fliseascs,  and  as  an  invaluable  therapeutical  means  in  nearly  all  forms  of  Nervous  Disease;  but 
not  as  a  specific  for  every  human  ill,  mental  and  physical. 

THE  ANATOMY    OF    INVERTEBRATED  ANIMALS. 

By  Thomas  Henry  Huxley,  LL.  D.,   F.  R.  S. 

I  vol.,  l2nio.      Illustrated.     596  pji.     Cloth,  $2.50. 

"  My  oljject  in  writing  the  book  has  been  to  make  it  useful  to  those  who  wish  to  become  ac- 
quainted with  the  broad  outlines  of  what  is  at  present  known  of  the  morphology  of  the  Iiivcrte- 
hrata  ;  thougli  I  have  not  avoided  the  incidental  mention  of  facts  connected  with  their  physiology 
and  their  distribution.  On  the  other  hand,  T  have  abstained  from  discussing  questions  of  etiol- 
ogy, not  1)ecanse  I  underestimate  tlicir  importance,  or  am  insensible  to  the  interest  of  the  gi^eat 
problem  of  evolution,  but  because,  to  my  mind,  the  growing  tendency  to  mix  up  etiological  specu- 
lations with  morphological  generalizations  will,  if  unchecked,  throw  biology  into  confusion." — 
From  Preface. 


D.  APPLE  TON  (S-    CO.'S  MEDICAL    WORKS. 


21 


HAND-BOOK    OF    SKIN     DISEASES.      By    Dr.    Isidor 

Neumann,  Lecturer  on  Skin  Diseases  in  the  Royal  University  of  Vienna. 

Translated  from  the  German,  second  edition,  with  Notes,  by  Lucius  D. 

EuLKLEY,  A.  M.,  M.  U.,  Surgeon  to  the  New  York  Dispensary,  Department 

of  Venereal  and  Skin  Diseases;  Assistant  to  the  SkinClinic  of  the  College 

of  Physicians  and  Surgeons,  New  York,  etc.,  etc. 

I  vol.,  8vo,  467  pp.,  and  66  Woodcuts.      Cloth,  $4;  sheep,  $5. 

Professor  Xeumann  ranks  sec-  ^ 

ond  only  to  Hebra,  whose  assist- 
ant he  was  for  many  years,  and  his 
work  may  be  considered  as  a  fair 
exponent  of  the  German  practice 
of  Dermatology.  The  book  is 
abundantly  illustrated  with  plates 
of  the  histology  and  pathology  of 
the  skin.  The  translator  has  en- 
deavored, by  means  of  notes  from 
French,  English,  and  American 
sources,  to  make  the  work  valua- 
ble to  the  student  as  well  as  to  the 
practitioner. 


"  It  is  a  work  which  I  shall  hearti- 
ly recommend  to  my  class  of  students 
at  the  University  of  Pennsylvania, 
and  one  which  I  feel  sure  will  do 
much  toward  enlightening;  the  pro- 
fession on  this  subject." — Louis  A. 
Dii/iring.  ', 

"  There  certainly  is  no  work  ex- 
tant which  deals  so  thoroughly  with 
the  Pathological  Anatomy  of  the  Skin 
£isdoes  this  hand-book." — N'ew  York 
Medical  Record. 

"I  have  already  twice  expressed 

my  favorable  opinion  of  the  book  in   -f jf, 

print,  and  am  glad  that  it  is  given  to        T' 
the  public  at  last." — yames  C.  White., 
Boston. 

' '  More  than  two  years  ago  we 
noticed  Dr.  Neumann's  admirable 
work  in  its  original  shape,  and  we  are 
therefore  absolved  from  the  necessity 
of  saying  more  than  to  repeat  our 
strong  recommendation  of  it  to  Eng- 
lish readers." — Practitioner. 


Lichen  scrofulosorum. 


THE    PATHOLOGY    OF    MIND.     Being  the  third  edition 

of  the  Second  Part  of  the  "Physiology  and  Pathology  of  Mind,"  recast, 
enlarged,  and  rewritten.     By  Henry  Maudsley,  M.  D.,  London. 

I  vol.,  l2mo,  580  pp.      $2. 

CONTENTS.— Chdiptev  I.  Sleeping  and  Dreaming;  II.  Hypnotism,  Somnambulism,  and 
Allied  States ;  III.  The  Causation  and  Prevention  of  Insanity:  (A)  Etiological ;  IV.  The  same 
continued;  V.  The  Causation  and  Prevention  of  Insanity :  (B)  Pathological;  VI.  The  Insanity  of 
Early  Life;  VII.  The  Symptomatology  of  Insanity;  VIII.  The  same  continued;  IX.  Clinical 
Groups  of  Mental  Disease ;  X.  The  Morbid  Anatomy  of  Mental  Derangement ;  XI.  The  Treat- 
ment of  Mental  Disorders. 

The  new  material  includes  chapters  on  "  Dreaming,"  "  Somnambulism  and  its  Allied  States," 
and  large  additions  in  the  chapters  on  the  "  Causation  and  Prevention  of  Insanity." 

"Unquestionably  one   of  the   ablest  and  most  "Dr.  Maudsley  has  had  the  courage  to  under- 

important  works  on  the  subject  of   which  it  treats     take,  and  the  skill  to  execute,  what_  is,  at  least  in 


that  has  ever  appeared,  and  does  credit  to  his  philo- 
sophical acumen  and  accurate  observation." — Medi- 
cal Record. 


English,  an  original  enterprise.  "- 
dav  Review. 


-London  Satur- 


22 


D.   APPLETON  &-   CO.'S  MEDICAL    WORKS. 


MEDICAL    RECOLLECTIONS    OF    THE   ARMY    OF 

THE    POTOMAC.      By   Jonathan    Letterman,    M.  D.,    late    Surgeon 
U.  S.  A.,  and  Medical  Director  of  the  Army  of  the  Potomac. 

I  vol.,  8vo,  194  pp.     Cloth,  $1. 

"  ^^'e  venture  to  assert  that  but  few  who  open     with   instruction,   will  care  to  do  otherwise  than 
this  volume  of  medical  annals,  pregnant  as  thJy  are     finish  them  at  a  sitting." — Medical  Record. 


RESPONSIBILITY      IN      MENTAL      DISEASES.       By 

Henry  Maudsley,  M.  D.,  London. 

I  vol.,  i2mo,  313  pp.     Cloth,  $1.50. 


"This  book  is  a  compact  presentation  of  those 
facts  and  principles  wliich  require  to  be  taken  into 
account  in  estimating  human  responsibility — not  le- 
gal responsibility  merely,  but  responsibility  for  con- 
duct in  the  family,  the  school,  and  all  phases  of 


social  relation,  in  which  obligation  enters  as  an 
element.  The  work  is  new  in  plan,  and  was  writ- 
ten to  supply  a  wide-fell  want  which  has  not  hither- 
to been  met." — The  Popular  Scieftce  Monthly. 


BODY    AND    MIND:   An  Inquiry  into  their  Connection  and 

Mutual  Influence,  especially  in  reference  to  Mental  Disorders;  an  enlarged 

and  revised  edition,  to  which  are  added  Psychological  Essays.     By  Henry 

Maudsley,  M.  D.,  London. 

I  vol.,  i2mo,  275  pp.     Cloth,  $1.50. 

The  general  plan  of  this  work  may  be  described  as  being  to  bring  man,  both  in  his  physical 
and  mental  relations,  as  much  as  possible  within  the  scope  of  scientific  inquiry. 

the  abundant  cases  compiled  by  the  medical  author- 
ities ;  but  the  physician,  on  the  other  hand,  had  no 
theoretical  clew  to  his  observations  beyond  a  smat- 
tering of  dogmatic  psychology  learned  at  college. 
To  effect  a  reconciliation  between  the  Psychology 
and  the  Pathology  of  the  mind,  or  rather  to  con- 
struct a  basis  for  both  in  a  common  science,  is  the 
aim  of  Dr.  Maudsley's  book." — London  Saturday 
Review. 

"A  representative  work,  which  every  one  must 
study  who  desires  to  know  what  is  doing  in  the  way 
of  real  progress,  and  not  mere  chatter,  about  men- 
tal physiology  and  pathology." — Lancet. 

"It  distinctly  marks  a  step  in  the  progress  of 
scientific  psychology." — The  Practitioner. 


"Dr.  Maudsley  has  had  the  courage  to  under- 
take, and  the  skill  to  execute,  what  is,  at  least  in 
English,  an  original  enterprise.  This  book  is  a 
manual  of  mental  science  in  all  its  parts,  embracing 
all  that  is  known  in  the  existing  state  of  physiology. 
.  .  .  Many  and  valuable  books  have  been  written 
by  English  physicians  on  insanity,  idiocy,  and  all 
the  forms  of  mental  aberration.  But  derangement 
had  always  been  treated  as  a  distinct  subject,  and 
therefore  empirically.  That  the  phenomena  of 
sound  and  unsound  minds  are  not  matters  of  dis- 
tinct investigation,  but  inseparable  parts  of  one  and 
the  same  inquiry,  seems  a  truism  as  soon  as  stated. 
But,  strange  to  say,  they  had  always  been  pursued 
separately,  and  been  in  the  hands  of  two  distinct 
classes  of  investigators.  The  logicians  and  meta- 
physicians occasionally  borrowed  a  stray  fact  from 


HEALTH,  AND  HOW  TO   PROMOTE  IT.     By  Richard 

McSherry,  M.  D.,  Professor  of  Practice  of  Medicine,  University  of  Mary- 
land ;  President  of  Baltimore  Academy  of  Medicine,  etc. 
I  vol.,  r2mo,  185  pp.     Cloth,  $1.25. 


"  An  admirable  production  which  should  find  its 
way  into  every  family  in  the  country.  It  comprises 
a  vast  amount  of  the  most  valuable  matter  expressed 
in  clear  and  terse  language,  and  the  subjects  of 
which  it  treats  are  of  the  deepest  interest  to  every 
human  being."— /"re/".  S.  D.  GROSS,  of  Jefferson 
Medical  College,  Philadelphia. 

"  On  the  whole,  this  little  book  seems  to  us  very 
well  adapted  to  its  purpose,  and  will,  we  hope,  have 
a  wide  circulation,  when  it  can  not  fail  to  do  much 
good." — American  Jour7ial  of  Medical  .Sciences. 

"It  is  the  work  of  an  able  physician,  and  is 
written  in  a  style  which  all  people  can  understand. 
It  deals  with  practical  topics,  and  its  ideas  are  set 
forth  so  pointedly  as  to  make  an  impression." — 
The  Independent . 


"  This  is  a  racy  little  book  of  185  pages,  full  of 
good  advice  and  important  suggestions,  and  written 
in  a  free  and  easy  style,  which  crops  out  in  con- 
tinued humor  and  crispness  by  which  the  advice  is 
seasoned,  and  which  render  the  reading  of  the  book 
a  pleasant  pastime  to  all,  whether  professionals  or 
non-prf)fessionals. " — Canadian  Journal  of  Medical 
Science. 

"  It  contains  a  great  deal  of  useful  information, 
stated  in  a  very  simple  and  attractive  vf^y.''''— Balti- 
more Gazette. 

"  This  is  one  of  the  best  popular  essays  on  the 
subject  we  have  ever  seen.  It  is  short,  clear,  posi- 
tive, sensible,  bright  and  entertaining  in  its  style, 
and  is  as  full  of  practical  suggestions  as  a  nut  is 
full  of  meat." — Literary  World. 


D.   APPLETON  &-   CO.'S  MEDICAL    WORKS. 


23 


THE    PHYSIOLOGY    OF   THE    MIND.     Beincr  the  First 

Part  of  a  third  edition,  revised,  enlarged,  and  in  a  great  part  rewritten,  of 

"  The  Physiology  and  Pathology  of  the  Mind."     By  Henry  Maudsley, 

M.  D.,  London. 

I  vol.,  i2mo,  547  pp.     Cloth,  $2. 


'6".— Chapter  I.  On  the  Method  of  th&  Study  of  the  Mind;  II.  The  Mind  and  the 
l;   III.   The  Spinal  Cord,  or  Tertiary  Nervous  Centers;   or,  Nervous  Centers  of 


CONTENTS. 
Nervous  System; 

Reflex  Action;  IV.  Secondary  Nervous  Centers,  or  Sensory  Ganglia;  Sensorium  Commune ;  V. 
Hemispherical  Ganglia;  Cortical  Cells  of  the  Cerebral  Hemispheres;  Ideational  Nervous  Cen- 
ters; Primary  Nervous  Centers;  Intellectorium  Commune;  VI.  The  Emotions ;  VII.  VoHtion; 
VIII.  Motor  Nervous  Centers,  or  Motorium  Commune  and  Actuation  or  Effection ;  IX.  Memory 
and  Imagination. 


"The  '  Physiology  of  the  Mind,'  by  Dr.  Mauds- 
ley,  is  a  very  engaginij  volume  to  read,  as  it  is  afresh 
and  vigorous  statement  of  the  doctrines  of  a  grow- 
ing scientific  school  on  a  subject  of  transcendent 
moment,  and,  besides  many  new  facts  and  impor- 
tant views  brought  out  in  the  text,  is  enriched  by  an 


instructive  display  of  notes  and  quotations  from 
authoritative  writers  upon  physiology  and  psychol- 
ogy ;  and  by  illustrative  cases,  whicli  add  materi- 
ally to  the  interest  of  the  book." — Popular  Science 
Mo7ithly. 


PHYSICAL   EDUCATION  ;  or,  THE  HEALTH    LAWS 

OF    NATURE.     By  Felix  L.  Oswald,  M.  D. 

i2mo,  cloth.     $1. 


"  Dr.  Oswald  is  a  medical  man  of  thorough 
preparation  and  large  professional  experience,  and 
an  extensively  traveled  student  of  nature  and  of 
men.  While  in  chirge  of  a  military  hospital  at 
-Vera  Cruz,  his  own  health  broke  down  from  long 
-'exposure  in  a  malarial  region ,  and  he  then  struck 
for  the  Mexican  mountains,  where  he  became  direct- 
or of  another  medical  establishment.  He  has  also 
journeyed  extensively  in  Europe,  South  America, 
and  the  United  States,  and  always  as  an  open-eyed, 
absorbed  observer  of  nature  and  of  men.  The 
'  Physical  Education '  is  one  of  the  most  whole- 
some and  valuable  books  that  have  emanated  from 
the  American  press  in  many  a  day.  Not  only  can 
everybody  understand  it,  and,  what  is  more,  y^^/ it, 
but  everybody  that  gets  it  will  be  certain  to  read  and 
re-read  it.  We  have  known  of  the  positive  and 
most  salutary  influence  of  the  papers  as  they  ap- 
peared in  the  '  Monthly, '  and  the  extensive  demand 
for  their  publication  in  a  separate  form  shows  how 
they  have  been  appreciated.  Let  those  who  are  able 
and  wish  to  do  good  buy  it  wholesale  and  give  it  to 
those  less  able  to  obtain  \t."-^TIie  Popular  Science 
Monthly. 

' '  Here  we  have  an  intelligent  and  sensible  treat- 
ment of  a  subject  of  great  importance,  viz.,  physi- 
cal education.  We  give  the  headings  of  some  of 
the  chapters,  viz.  :  Diet ;  In-door  Life  ;  Out-door 
Life  ;  Gymnastics  ;  Clothing  ;  Sleep  ;  Recreation  ; 
Remedial  Education  ;  Hygienic  Precautions  ;  Pop- 
ular Fallacies.  These  topics  are  discussed  in  a  plain, 
common-sense  style  suited  to  the  popular   mind. 


Books  of  this  character  can  not  be  too  widely  read." 
— Albany  {N.  Y.)  Argus. 

"Dr.  Oswald  is  as  epigrammatic  as  Emerson, 
as  spicy  as  Montaigne,  and  as  caustic  as  Heine. 
And  yet  he  is  a  pronounced  vegetarian.  His  first 
chapter  is  devoted  to  a  consideration  of  the  diet 
suitable  for  human  beings  and  infants.  In  the  next 
two  he  contrasts  life  in  and  out  of  doors.  He  then 
gives  his  ideas  on  the  subjects  of  gymnastics,  cloth- 
ing, sleep,  and  recreation.  He  suggests  a  system  of 
remedial  education  and  hygienic  precautions,  and 
he  closes  with  a  diatribe  against  popular  fallacies." 
— Philadelphia  Press. 

"  It  is  a  good  sign  that  books  on  physical  train- 
ing multiply  in  this  age  of  mental  straining.  Dr. 
Felix  L.  Oswald,  author  of  the  above  book,  may  be 
somewhat  sweeping  in  his  statements  and  beliefs, 
but  every  writer  who,  like  him,  clamors  for  sim- 
plicity, naturalness,  and  frugality  in  diet,  for  fresh 
air  and  copious  exercise,  is  a  benefactor.  Let  the 
dyspeptic  and  those  who  are  always  troubling  them- 
selves and  their  friends  about  their  manifold  ail- 
ments take  Dr.  Oswald's  advice  and  look  more  to 
their  aliments  and  their  exercise." — New  York 
Herald. 

"One  of  the  best  books  that  can  be  put  in  the 
hands  of  young  men  and  women.  It  is  very  inter- 
esting, full  of  facts  and  wise  suggestions.  It  points 
out  needed  reforms,  and  the  way  we  can  become  a 
strong  and  healthy  people.  It  deserves  a  wide  cir- 
culation."— Bost07i  Cotn7?tomuealth. 


GALVANO -THERAPEUTICS.       The     Physiological    and 

Therapeutical  Action  of  the  Galvanic  Current  upon  the  Acoustic,  Optic, 

Sympathetic,  and  Pneumogastric  Nerves.     By  William  B.  Neftel. 

Fourth  edition,     i  vol.,  i2mo,  161  pp.     Cloth,  $1.50. 

This  book  has  been  republished  at  the  request  of  several  aural  surgeons  and  other  professional 
gentlemen,  and  is  a  valuable  treatise  on  the  subjects  of  which  it  treats.  Its  author,  formerly  visit- 
ing physician  to  the  largest  hospital  of  St.  Petersburg,  has  had  the  very  best  facilitifes  for  investi- 
gation. 

"This  little  work  shows,  as  far  as  it  goes,  full  "  Those  who  use  electricity  should  get  this  work, 

knowledge  of  what  has  been  done  on  the  subjects  and  those  who  do  not  should  peruse  it  to  learn  that 

treated  of,  and  the  author's  practical  acquaintance  there  is  one  more  therapeutical  agent  that  they  could 

with  them." — New  York  Medical  journal.  and  should  possess." — The  Medical  Investigator. 


24 


D.  APPLE  TON  (S-   CO.'S  MEDICAL    WORKS. 


OVARIAN  TUMORS;  their  Pathology,  Diagnosis,  and  Treat- 
ment, with  Reference  especially  to  Ovariotomy.  By  E.  R.  Peaslee,  M.  D., 
Professor  of  Diseases  of  Women  in  Dartmouth  College  ;  formerly  Professor 
of  Obstetrics  and  Diseases  of  Women  in  the  New  York  Medical  College,  etc. 

I  vol.,  8vo,  551  pp.     Illustrated  with  many  Woodcuts,  and  a  Steel  Engraving  of  Dr.  E.  McDow- 
ell, the  "  Eather  of  Ovariotomy. "     Cloth,  $5;  sheep,  $6. 

This  valuable  work,  embracing  the  results  of  many  years  of  successful  experience  in  the  de- 
partment of  which  it  treats,  will  prove  most  acceptable  to  the  entire  profession ;  while  the  high 
standing  of  the  author  and  his  knowledge  of  the  subject  combine  to  make  the  book  the  best  in  the 
language.  Eully  illustrated,  and  abounding  with  information,  the  result  of  a  prolonged  study  of 
the  subject,  the  work  should  be  in  the  hands  of  every  physician  in  the  country. 

•  In  closing-  our  review  of  this  work,  we  can  not 


avoid  again  expressing:  our  appreciation  of  the  thor- 
ough study,  the  careful  and  honest  statements,  and 
candid  spirit,  which  characterize  it.  For  the  use  of 
the  sttidcnt  we  should  give  the  preference  to  Dr. 
Peaslee' s  work,  7iot  only  from  its  cotnpleteness,  but 
from  its  more  methodical  arrangement." — Ameri- 
can Journal  of  Medical  Sciences. 


' '  We  deem  its  careful  perusal  indispensable  to 
all  who  would  treat  ovarian  tumors  with  a  good  con- 
science."— American  yournal  of  Obstetrics. 

"  It  shows  prodigal  industry,  and  embodies  with- 
in its  five  hundred  and  odd  pages  pretty  much  all 
that  seems  worth  knowing  on  the  subject  of  ovarian 
diseases." — Philadelphia  Medical  Times. 


A   TREATISE    ON    DISEASES    OF   THE    BONES.     By 

Thomas  M.  Markoe,  M.  D.,  Professor  of  Surgery  in  the  College  of  Physi- 
cians and  Surgeons,  New  York,  etc.     With  numerous  Illustrations. 
I  vol.,  8vo,  416  pp.     Cloth,  $4.50. 

Specimen  of  Illustration.  This  valuable  work  is  a  trea- 

tise on  Diseases  of  the  Bones, 
embracing  their  structural 
changes  as  affected  by  disease, 
their  clinical  history  and  treat- 
ment, including  also  an  account 
of  the  various  tumors  which 
'W\  grow  in  or  upon  them.  None 
of  the  injuries  of  bone  are  in- 
cluded in  its  scope,  and  no  /oiftt 
diseases,  excepting  where  the 
condition  of  the  bone  is  a  prime 
factor  in  the  problem  of  disease. 
As  the  work  of  an  eminent  sur- 
geon of  large  and  varied  experi- 
ence, it  may  be  regarded  as  the  best  on  the  subject,  and  a  valuable  contribution  to  medical 
literature. 


DR.  PEREIRA'S  ELEMENTS  OF  MATERIA  MEDICA 

AND  THERAPEUTICS.  Abridged  and  adapted  for  the  Use  of  Medical 
and  Pharmaceutical  Practitioners  and  Students,  and  comprising  all  the 
Medicines  of  the  British  Pharmacopoeia,  with  such  others  as  are  frequently 
ordered  in  Prescriptions,  or  required  by  the  Physician.  Edited  by  Robert 
Bentley  and  Theophilus  Redwood. 
New  edition.     Brought  down  to  1872.      i  vol.,  royal  8vo,  1,093  PP-     Cloth,  $7;  sheep,  $8. 


NOTES  ON   NURSING 

Florence  Nightingale. 


What  it  is,  and  what  it  is  not.     By 


I  vol.,  i2mo,  140  pp. 


Cloth,  75  cents. 

those  who  have  personal  charge  of  the 


These  notes  are  meant  to  give  hints  for  thought  t 
health  of  others. 

Every-day  sanitary  knowledge,  or  the  knowledge  of  nursing,  or,  in  other  words,  of  how  to  put 
the  constitution  in  such  a  state  as  that  it  will  have  no  disease  or  that  it  can  recover  from  disease, 
is  recognized  as  the  knowledge  which  every  one  ought  to  have — distinct  from  medical  knowledge, 
which  only  a  profession  can  have. 


D.   APPLETON  &^   CO:S  MEDICAL    WORKS. 


25 


A   TEXT-BOOK   OF    PRACTICAL   MEDICINE.     With 

Particular  Reference  to  Physiology  and  Pathological  Anatomy.  By  the 
late  Dr.  Felix  von  Niemeyer,  Professor  of  Pathology  and  Therapeutics; 
Director  of  the  Medical  Clinic  of  the  University  of  Tubingen.  Translated 
from  the  eighth  German  edition,  by  special  permission  of  the  author,  by 
George  H.  Humphreys,  M.  D.,  one  of  the  Physicians  to  Trinity  Infirmary, 
Fellow  of  the  New  York  Academy  of  Medicine,  etc.,  and  Charles  E. 
Hackley,  M.  D.,  one  of  the  Physicians  to  the  New  York  Hospital  and 
Trinity  Infirmary,  etc. 

Revised  edition  of  1880.     2  vols.,  8vo,  1,628  pages.     Cloth,  $9;  sheep,  $11. 

The  author  undertakes,  first,  to  give  a  picture  of  disease  which  shall  be  as  life-like  and  faithful 
to  nature  as  possible,  instead  of  being  a  mere  theoretical  scheme ;  secondly,  so  to  utilize  the  more 
recent  advances  of  pathological  anatomy,  physiology,  and  physiological  chemistry,  as  to  furnish  a 
clearer  insight  into  the  various  processes  of  disease. 

The  work  has  met  with  the  most  flattering  reception  and  deserved  success  ;  has  been  adopted 
as  a  text-book  in  many  of  the  medical  colleges  both  in  this  country  and  in  Europe ;  and  has  re- 
ceived the  very  highest  encomiums  from  the  medical  and  secular  press. 

"  This  new  American  edition  of  Niemeyer  fully 
sustains  the  reputation  of  previous  ones,  and  may 
be  considered,  as  to  style  and  matter,  superior  to 
any  translation  that  could  have  been  made  from  the 
latest  German  edition.  It  will  be  recollected  that 
since  the  death  of  Professor  Niemeyer,  in  1871,  his 
work  has  been  edited  by  Dr.  Eugene  Seitz.  Although 
the  latter  gentleman  has  made  many  additions  and 
changes,  he  has  destroyed  somewhat  the  individual- 
ity of  the  original.  The  American  editors  have 
wisely  resolved  to  preserve  the  style  of  the  author, 
and  adhere,  as  closely  as  possible,  to  his  individual 
views  and  his  particular  style.  Extra  articles  have 
been  inserted  on  chronic  alcoholism,  morphia-poi- 
soning, paralysis  agitans,  scleroderma,  elephantiasis, 
progressive  pernicious  ansemia,  and  a  chapter  on 
yellow  fever.  The  work  is  well  printed  as  usual." 
— Medical  Record. 


' '  The  first  inquiry  in  this  country  regarding  a 
German  book  generally  is,  '  Is  it  a  work  of  practi- 
cal value  ? '  Without  stopping  to  consider  the  just- 
ness of  the  American  idea  of  the  '  practical,'  we  can 


unhesitatingly  answer,  '  It  is  ! '  " — New  York  Medi- 
cal Journal. 

"  It  is  comprehensive  and  concise,  and  is  char- 
acterized by  clearness  and  originality." — Dublin 
Quarterly  Journal  of  Medicine. 

"  Its  author  is  learned  in  medical  literature  ;  he 
has  arranged  his  materials  with  care  and  judgment, 
and  has  thought  over  them." — The  La?icet. 

' '  While,  of  course,  we  can  not  undertake  a  re- 
view of  this  immense  work  of  about  1,600  pages  in 
a  journal  of  the  size  of  ours,  we  may  say  that  we 
have  examined  the  volumes  very  carefully,  as  to 
whether  to  recommend  them  to  practitioners  or  not ; 
and  we  are  glad  to  say,  after  a  careful  review,  '  Buy 
the  book.'  The  chapters  are  succinctly  written. 
Terse  terms  and,  in  the  main,  brief  sentences  are 
used.  Personal  experience  is  recorded,  with  a  prop- 
er statement  of  facts  and  observations  by  other  au- 
thors who  are  to  be  trusted.  A  very  excellent  index 
is  added  to  the  second  volume,  which  helps  very 
much  for  ready  reference."  —  Virgittia  Medical 
Monthly. 


ESSAYS    ON    THE    FLOATING    MATTER    OF    THE 

AIR,  in  Relation  to  Putrefaction  and  Infection.     By  Professor  John  Tyn- 

DALL,  F.  R.  S. 

l2mo.      Cloth,  $1.50. 

CONTENTS. — I.  On  Dust  and  Disease ;  II.  Optical  Deportment  of  the  Atmosphere  in  Re- 
lation to  Putrefaction  and  Infection ;  III.  Further  Researches  on  the  Deportment  and  Vitality  of 
Putrefactive  Organisms ;  IV.  Fermentation,  and  its  Bearings  on  Surgery  and  Medicine ;  V.  Spon- 
taneous Generation ;  Appendix. 


"Professor  Tyndall's  book  is  a  calm,  patient, 
clear,  and  thorough  treatment  of  all  the  questions 
and  conditions  of  nature  and  society  involved  in 
this  theme.  The  work  is  lucid  and  convincing,  yet 
not  prolix  or  pedantic,  but  popular  and  really  en- 
joyable. It  is  worthy  of  patient  and  renewed 
study." — Philadelphia  Times. 

' '  The  matter  contained  in  this  work  is  not  only 
presented  in  a  very  interesting  way,  but  is  of  great 
value." — Boston  Jour7ial  of  Commerce. 

"The  germ  theory  of  disease  is  most  intelli- 
gently presented,  and  indeed  the  whole  work  is 
instinct  with  a  high  intellect." — Boston  Common- 
wealth. 


"  In  the  book  before  us  we  have  the  minute  de- 
tails of  hundreds  of  observations  on  infusions  ex- 
posed to  optically  pure  air ;  infusions  of  mutton, 
beef,  haddock,  hay,  turnip,  liver,  hare,  rabbit, 
grouse,  pheasant,  salmon,  cod,  etc,  ;  infusions 
heated  by  boiling  water  and  by  boiling  oil,  some- 
times for  a  few  moments  and  sometimes  for  several 
hours,  and,  however  varied  the  mode  of  procedure, 
the  result  was  invariably  the  same,  with  not  even  a 
shade  of  uncertainty.  The  fallacy  of  spontaneous 
generation  and  the  probability  of  the  germ  theoiy 
of  disease  seem  to  us  the  inference,  and  the  only 
inference,  that  can  be  drawn  from  the  results  of 
nearly  ten  thousand  experiments  performed  by  Pro- 
fessor Tyndall  within  the  last  two  years." — Pitts- 
burg Telegraph. 


26 


D.  APPLE! ON  6-   CO.'S  MEDICAL    WORKS. 


THE     APPLIED     ANATOMY     OF     THE     NERVOUS 

.  SYSTEM,  being  a  Study  of  this  Portion  of  the  Human  Body  from  a  Stand- 
point of  its  General  Interest  and  Practical  Utility,  designed  for  Use  as  a 
Text-book  and  as  a  Work  of  Reference.  By  Ambrose  L.  Ranney,  A.  M., 
iVI.  D.,  Professor  of  the  Anatomy  and  Physiology  of  the  Nervous  System  in 
the  New  York  Post-Graduate  Medical  School  and  Hospital ;  Professor  of 
Nervous  and  Mental  Diseases  in  the  Medical  Department  of  the  University 
of  Vermont,  etc. 

8vo.     New  edition,  rewritten,  enlarged,  and  profusely  illustrated.     Cloth,  $5 ;  sheep,  $6. 


JJistribution  of  the  Hypo-glossal  Nerve. 


{  The  followi7ig  are  some  of  the  7iotices  of  the  first  edilio?t  :) 


"This  is  an  excellent  work,  timely,  practical, 
and  well  executed.  It  is  safe  to  say  that,  besides 
Hammond's  work,  no  book  relating:  to  the  nervous 
system  has  hitherto  been  published  in  this  country 
equal  to  the  present  volume,  and  nf)thing;  superior 
to  it  is  accessible  to  the  American  practitioner." — 
Medical  Herald. 

"  There  are  many  books,  to  be  sure,  which  con- 
tain here  and  there  hints  in  this  field  of  great  value 
to  the  physician,  but  it  is  Dr.  Ranney's  merit  to 
have  collected  these  scattered  items  of  intere.st,  and 
to  have  woven  them  into  an  harmonious  whole, 
thereby  producing^  a  work  of  wide  scope  and  of  cor- 
respondingly wide  u.sefulness  to  the  practicing  physi- 
cian. 

"The  book,  it  will  be  perceived,  is  of  an  emi- 
nently practical  character,  and,  as  such,  is  addressed 
to  thf)se  who  can  not  afford  the  time  for  the  perusal 
of  the  larger  text-books,  and  who  must  read  as  they 
run." — New  York  Medical  fournal. 


"It  is  an  admitted  fact  that  the  subject  treated 
of  in  this  work  is  one  sufficiently  obscure  to  the  pro- 
fession generally  to  make  any  work  tending  to  elu- 
cidation mo.st  welcome.  .  .  .  We  earnestly  recom- 
mend this  work  as  one  unusually  worthy  of  study." 
— Buffalo  Medical  and  Surgical  yoiirnal. 

"  Dr.  Ranney  has  firmly  grasped  the  essential 
features  of  the  results  of  the  latest  study  of  the 
nervous  system.  His  work  will  do  much  toward 
popularizing  this  study  in  the  profession. 

"  We  are  sure  that  all  our  readers  will  be  quite 
as  much  pleased  as  ourselves  by  its  careful  study." 
— Detroit  Lancet. 

"A  useful  and  attractive  book,  suited  to  the 
time." — I.otiisville  Medical  News. 

"Our  impressions  of  this  work  are  highly  fa- 
vorable as  regards  its  practical  value  to  students,  as 
well  as  to  educated  medical  men." — Pacific  Medical 
and  Surgical  yournal. 


D.   APPLETON  &-   CO.'S  MEDICAL    WORKS. 


27 


"The  work  shows  gfreat  care  in 
its  preparation.  We  predict  for  it  a 
larjje  sale  among  the  more  progres- 
sive practitioners." — Michigan  Medi- 
cal News. 

"  We  are  acquainted  with  no  re- 
cent work  which  deals  with  the  sub- 
ject so  thoroughly  as  this  ;  hence,  it 
should  commend  itself  to  a  large  class 
of  persons,  not  merely  specialists,  but 
those  who  aspire  to  keep  posted  in  3\ 
all  important  advances  in  the  science 
and  art  of  medicine," — Maryland 
Medical  yournal. 

' '  This  work  was  originally  ad- 
dressed to  medical  under-graduates, 
but  it  will  be  equally  interesting  and 
valuable  to  medical  practitioners  who 
still  acknowledge  themselves  to  be 
|:9  students.  It  is  to  be  hoped  that  their 
number  is  not  small." — New  Orleans 
Medical  and  Surgical  jfoui-nal. 

"  We  think  the  author  has  cor- 
rectly estimated  the  necessity  for  such 
a  volume,  and  we  congratulate  him 
upon  the  manner  in  which  he  has 
e.xecuted  his  task. 

"  As  a  companion  volume  to  the 
recent  works  on  the  diseases  of  the 
nervous  system,  it  is  issued  in  good 
time."  —  North  Carolina  Medical 
Journal. 

"  A  close  and  careful  study  of  this 
work,  we  feel  convinced,  will  impart 
to  the  student  a  large  amount  of  practical  knowledge  which  could  not 
be  gained  elsewhere,  except  by  wading  through  the  enormous  quan- 
tity of  neurological  literature  which  has  appeared  during  past  years, 
a  task  which  few  would  have  either  time  or  inclination  to  accomplish. 
Here  it  will  all  be  found  condensed,  simplified,  and  systematically 
arranged.  The  nature  of  the  work  is  so  fully  explained  in  its  title 
that  little  or  nothing  on  that  point  need  be  said  here.  We  will,  how- 
ever, say  that  the  whole  subject  is  treated  in  a  lucid  manner,  and  that, 
so  far  as  we  are  able  to  judge,  nothing  seems  left  out  which  could  in 
any  way  improve  or  add  to  the  value  of  the  book." — Medical  and 
Surgical  Reporter  {Philadelphia). 

' '  Dr.  Ranney  has  done  a  most  useful  and  praiseworthy  task  in 
that  he  will  have  saved  many  of  the  profession  from  the  choice  of 
going  through  the  research  we  have  indicated,  or  remaining  in  igno- 
rance of  many  things  most  essential  to  a  sound  medical  'knowledge:.'"— Medical Hecord. 

' '  We  are  sure  that  this  book  will  be  well  received,  and  will  prove  itself  a  very  useful  companion  both 
for  regular  students  of  anatomy  and  physiology,  and  also  for  practitioners  who  wish  to  work  up  the  diag- 
nosis of  cases  of  disorder  of  the  nervous  system." — Canada  Medical a)id Surgical  yournal. 

"  Dr.  Ranney  has  done  his  work  well,  and  given  accurate  information  in  a  simple,  readable  style." — 
Philadelphia  Medical  Tijnes. 


The  Deep  Branch  of  the  External 
Plantar  Nerve. 


The  Small  Sciatic  Nerve,  with  its 
Branches  of  Distribution  and 
Termination. 


A     MINISTRY     OF     HEALTH     AND     OTHER     AD- 
DRESSES.    By  Dr.  B.  W.  Richardson,  M.  D.,  M.  A.,  F.  R.  S.,  etc.,  etc. 

I  vol.,  i2mo,  354  pp.     Cloth,  $1.50. 


' '  The  author  is  so  widely  and  favorably  known 
that  any  book  which  bears  his  name  will  receive  re- 
spectful attention.  He  is  one  of  those  highly  edu- 
cated yet  practical,  public-spirited  gentlemen  who 
adorn  the  profession  of  medicine  and  do  far  more 
than  their  share  toward  elevating  its  position  before 
the  public.  This  book,  owing  to  the  character  of 
the  matter  considered  and  the  author's  attractive 
style,  affords  means  for  relaxation  and  instruction 
to  everv  thoughtful  person." — Medical  Gazette. 

"  This  book  is  made  up  of  a  number  of  addresses 
on  sanitary  subjects,  which  Dr.  Richardson  deliv- 
ered at  various  times  in  Great  Britain,  and  which 
are  intended  to  invite  attention  to  the  pressing  re- 
forms that  are  making  progress  in  medical  science. 
The  work,  which  has  the  great  merit  of  being  writ- 


ten in  the  simplest  and  clearest  language,  gives 
special  attention  to  the  origin  and  causes  of  diseases, 
and  a  demonstration  of  the  physical  laws  by  which 
they  may  be  prevented.  .   .   . 

"  The  author  does  not,  like  some  members  of  his 
profession,  enter  into  a  learned  description  of  cures, 
but  traces  the  causes  of  diseases  with  philosophical 
precision.  The  book  contains  what  every  one  should 
know,  and  members  of  the  medical  profession  will 
not  find  a  study  of  it  in  vain." — Philadelphia  En- 
quirer. 

"  The  wide  study  of  these  lectures  by  both  the 
profession  and  the  laity  would  greatly  advance  the 
interests  of  both  by  stimulating  thought  and  action 
respecting  the  most  vital  subjects  that  can  engage 
the  human  mind." — Detroit  Lancet. 


28  ^^-   APPLE  TON  <S-    CO.'S  MEDICAL    WORKS. 

DISEASES  OF  MODERN   LIFE.     By  Dr.  B.  W.  Richard- 
son, M.  D.,  M.  A.,  F.  R.  S.,  etc.,  etc. 

I  vol.,  i2mo,  520  pp.      Cloth,  $2. 

"  In  this  valuable  and  deeply  interesting  work  of  atmospheric  temperature,  of  atmospheric  press- 

Dr.   Richardson  treats  the  nervous  system  as  the  ure,  of  moisture,  winds,  and  atmospheric  chemical 

very  principle  of  life,  and  he  shows  how  men  do  it  changes,  which  are  of  great  general  interest." — Na- 

violence,  )'et  expect  immunity  where  the  natural  sen-  ture. 
iencQ  \sdeaXh.:'—aiaHesto>i  Courier.  "Particular  attention  is  given  to  diseases  from 

"The  work  is  of  great  value  as  a  practical  g^uide  worry  and  mental  strain,  from  the  passions,  from 

to  enable  the  reader  to  detect  and  avoid  various  alcohol,  tobacco,   narcotics,  food,  impure  air,  late 

sources  of  disease,  and  it  contains,  in  addition,  sev-  hours,   and  broken   sleep,   idleness,   intermarriage, 

eral  introductor)-  chapters  on  natural  life  and  natu-  etc.,  thus  touching  upon  causes  which  do  not  enter 

ral  death,  the  phenomena  of  disease,  disease  ante-  into  the  consideration  of  sickness." — Bost07i  Com- 

cedent  to  birth,  and  on  the  effects  of  the  seasons,  7nonwealth. 

THE  WATERING-PLACES  AND  MINERAL  SPRINGS 

OF  GERMANY,  AUSTRIA,  AND   SWITZERLAND.     With  Notes  on 

Climatic   Resorts   and   Consumption,  Sanitariums,   Peat,   Mud,   and    Sand 

Baths,  Whey  and  Grape  Cures,  etc.     By  Edward  Gutmann,  M.  D 

With  Illustrations,  Comparative  Tables,  and  a  Colored  Map,  explaining  the  Situation  and  Chemi- 
cal Composition  of  the  Spas,     i  vol.,  i2mo.     Cloth,  $2.50. 

'' Dr.  Gutmann  has  compiled  an  excellent  medi-  tions,   with   the   therapeutical  applications   of   the 

cal  guide,  which  gives  full  information  on  the  man-  mineral  waters,   are  very  thoroughly  presented  in 

ners   and   customs   of    living  at   all   the   principal  separate  parts  of  the  volume." — New  York  Tiines. 
watering-places  in  Europe.    The  chemical  composi- 

A    PRACTICAL    MANUAL    ON    THE    TREATMENT 

OF  CLUB-FOOT.     By  Lewis  A.  Sayre,  M.  D.,  Professor  of  Orthopedic 
Surgery  and  Clinical  Surgery  in  Bellevue  Hospital  Medical  College;  Con- 
sulting Surgeon  to  Bellevue  Hospital,  Charity  Hospital,  etc.,  etc. 
Fourth  edition,  enlarged  and  corrected,     i  vol.,  i2mo.     Illustrated.     Cloth,  $1.25. 

"A  more  extensive  experience  in  the  treatment  of  club-foot  has  proved  that  the  doctrines  taught 
in  my  first  edition  were  correct,  viz.,  that  in  all  cases  of  congenital  club-foot  the  treatment  should 
commence  at  birth,  as  at  that  time  there  is  generally  no  difficulty  that  can  not  be  overcome  by  the 
ordinary  family  physician  ;  and  that,  by  following  the  simple  rules  laid  down  in  this  volume,  the 
great  majority  of  cases  can  be  relieved,  and  many  cured,  without  any  operation  or  surgical  inter- 
ference. If  this  early  treatment  has  been  neglected,  and  the  deformity  has  been  permitted  to  in- 
crease by  use  of  the  foot  in  its  abnormal  position,  surgical  aid  may  be  requisite  to  overcome  the 
difficulty ;  and  I  have  here  endeavored  to  clearly  lay  down  the  rules  that  should  govern  the  treat- 
ment of  this  class  of  cases." — Preface. 

"The  book  will  very  well  satisfy  the  wants  of  use,  as  stated,  it  is  intended.'' — New  York  Medical 
the   majority   of   general   practitioners,    for    whose      yournal. 

COMPENDIUM      OF     CHILDREN'S     DISEASES.      A 

Hand-Book  for  Practitioners  and  Students.  By  Dr.  Johann  Steiner, 
Professor  of  the  Diseases  of  Children  in  the  University  of  Prague.  Trans- 
lated from  the  second  German  edition  by  Lawson  Tait,  F.  R.  C.  S.,  Sur- 
geon to  the  Birmingham  Hospital  for  Wornen. 

I  vol.,  8vo.     Cloth,  $3.50;  sheep,  $4.50. 

"Dr.  Steiner's  book  has  met  with  such  marked  success  in  Germany  that  a  second  edition  has 
already  appeared,  a  circumstance  which  has  delayed  the  appearance  of  its  English  form,  in  order 
that  I  might  lie  able  to  give  his  additions  and  corrections. 

"  I  have  added  as  an  Appendix  the  '  Rules  for  Management  of  Infants,'  which  have  been  issued 
by  the  staff  of  the  Birmingham  Sick  Children's  Hospital,  because  I  think  that  they  have  set  an  ex- 
ample, bv  freely  distributing  these  rules  among  the  poor,  for  which  they  can  not  be  sufficiently 
commended,  and  which  it  would  be  wise  for  other  sick  children's  hospitals  to  follow. 

"  I  have  also  added  a  few  notes,  chiefly,  of  course,  relating  to  the  surgical  ailments  of  chil- 
dren."— Extract  from  Translator's  Preface. 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


29 


HEALTH  :   A  Hand-Book   for  Households  and   Schools.     By 

Edward  Smith,  M.  D.,  F.  R.  S.,  Fellow  of  the  Royal  College  of  Physicians 

and  Surgeons  of  England,  etc. 

I  vol.,  i2mo.     Illustrated.     198  pp.     Cloth,  $1. 

It  is  intended   to  inform  the  mind  on  the  subjects  involved  in  the  word  Health,  to  show  how 
health  may  be  retained  and  ill-health  avoided,  and  to  add  to  the  pleasure  and  usefulness  of  life. 


"  The  author  of  this  manual  has  rendered  a  real 
service  to  families  and  teachers.  It  is  not  a  mere 
treatise  on  health,  such  as  would  be  written  by  a 
medical  professor  for  medical  students.  Nor  is  it 
a  treatise  on  the  treatment  of  disease,  but  a  plain, 
common-sense  essay  on  the  prevention  of  most  of 
the  ills  that  flesh  is  heir  to.  There  is  no  doubt  that 
much  of  the  sickness  with  which  humanity  is  af- 
flicted is  the  result  of  ignorance,  and  proceeds  from 


the  use  of  improper  food,  from  defective  drainage, 
overcrowded  rooms,  ill-ventilated  workshops,  im- 
pure water,  and  other  like  preventable  causes. 
Legislation  and  municipal  regulations  may  do 
something  in  the  line  of  prevention,  but  the  people 
themselves  can  do  a  great  deal  more — particularly 
if  properly  enlightened  ;  and  this  is  the  purpose  of 
the  book." — Albany  Jourtial. 


LECTURES  ON  ORTHOPEDIC  SURGERY  AND  DIS- 
EASES OF  THE  JOINTS.  By  Lewis  A.  Sayre,  M.  D.,  Professor  of 
Orthopedic  Surgery  and  Clinical  Surgery  in  Bellevue  Hospital  Medical  Col- 
lege;  Consulting  Surgeon  to  Bellevue  Hospital,  Charity  Hospital,  etc.,  etc. 

Second  edition,  revised  and  greatly  enlarged,  with  324  Illustrations,     i  vol.,  8vo,  569  pp.     Cloth, 

$5;  sheep,  $6. 

This  edition  has  been  thoroughly  revised  and  rearranged,  and  the  subjects  classified  in  the  ana- 
tomical and  pathological  order  of  their  development.  Many  of  the  chapters  have  been  entirely 
rewritten,  and  several  new  ones  added,  and  the  whole  work  brought  up  to  the  present  time,  with 
all  the  new  improvements  that  have  been  developed  in  this  department  of  surgery.  Many  new 
engravings  have  been  added,  each  illustrating  some  special  point  in  practice. 

Specimen  of  Illustration. 


"The  name  of  the  author  is  a  sufficient  guar- 
antee of  its  excellence,  as  no  man  in  America  or 
elsewhere  has  devoted  such  unremitting  attention 
for  the  past  thirty  years  to  this  department  of  Sur- 
gery, or  given  to  the  profession  so  many  new  truths 
and  laws  as  applying  to  the  pathology  and  treat- 
ment of  deformities." — Western  Lancet. 

"  The  name  of  Lewis  A.  Sayre  is  so  intimately 
connected  and  identified  with  orthopsedics  in  all  its 
branches,  that  a  book  relating  his  experience  can 
not  but  form  an  epoch  in  medical  science,  and  prore 
a  blessing  to  the  profession  and  humanity.  Dr. 
Sayre's  views  on  many  points  differ  from  those 
entertained  by  other  surgeons,  but  the  great  suc- 
cesses he  has  obtained  fully  warrant  him  in  main- 
taining the  'courage  of  his  opinions.'  " — AjnericaJi 
yournal  of  Obstetrics. 


' '  Dr.  Sayre  has  stamped  his  individuality  on 
every  part  of  his  book.  Possessed  of  a  taste  for 
mechanics,  he  has  admirably  utilized  it  in  so  modi- 
fying the  inventions  of  others  as  to  make  them  of 
far  greater  practical  value.  The  care,  patience,  and 
perseverance  which  he  exhibits  in  fulfilling  all  the 
conditions  necessary  for  success  in  the  treatment  of 
this  troublesome  class  of  cases  are  worthy  of  all 
praise  and  imitation." — Detroit  Review  of  Medi- 
cine. 

''Its  teaching  is  sound,  and  the  originality 
throughout  very  pleasing ;  in  a  word,  no  man 
should  attempt  the  treatment  of  deformities  of  joint 
affections  without  being  familiar  with  the  views 
contained  in  these  lectures." — Catiada  Medical  and 
Surgical  yournal. 


30 


D.  APPLETON  &-   CO.'S  MEDICAL    WORKS. 


LECTURES    UPON    DISEASES    OF    THE    RECTUM 

AND    THE    SURGERY    OF    THE    LOWER    BOWEL.      Delivered  at 
the  Bellevue  Hospital  Medical  College  by  W.  H.  Van  Buren,  M.  D.,  late 
Professor  of  the  Principles  and  Practice  of  Surgery  in  the  Bellevue  Hospi- 
tal Medical  College,  etc.,  etc. 
Second  edition,  revised  and  enlarged,     i  volume,  8vo,  412  pp.,  with  27  Illustrations  and  complete 

Cloth,  $3;  sheep,  $4. 

' '  The  reviewer  too  often  finds  it  a  difficult 


Index. 
Specimen  of  Illustration. 


task  to  discover  points  to  praise,  in  order  that 
his  criticisms  may  not  seem  one-sided  and  un- 
just. These  lectures,  however,  place  him  upon 
the  other  horn  of  the  dilemma,  viz.,  to  find 
somewhat  to  criticise  severely  enough  to  clear 
himself  of  the  charge  of  indiscriminating  lau- 
dation. Of  course,  the  author  upholds  some 
views  which  conflict  with  other  authorities,  but 
he  substantiates  them  by  the  most  powerful  of 
arguments,  viz. ,  a  large  experience,  the  results 
of  which  are  enunciated  by  one  who  elsewhere 
shows  that  he  can  appreciate,  and  accord  the 
due  value  to,  the  work  and  experience  of 
others. ' ' — Archives  of  Medicine. 

' '  The  present  is  a  new  volume  rather  than 
a  new  edition.  Both  its  size  and  material 
are  vastly  beyond  its  predecessor.  The  same 
scholarly  method,  the  same  calm,  convincing 
statement,  the  same  wise,  carefully  matured 
counsel,  pervade  every  paragraph.  The  dis- 
comfort and  dangers  of  the  diseases  of  the 
rectum  call  for  greater  consideration  than 
they  usually  receive  at  the  hands  of  the  pro- 
fession."— Deti'oit  Lancet. 

"  These  lectures  are  twelve  in  number,  and 
may  be  taken  as  an  excellent  epitome  of  our 
present  knowledge  of  the  diseases  of  the  parts 
in  question.  The  work  is  full  of  practical 
matter,  but  it  owes  not  a  little  of  its  value  to 
the  original  thought,  labor,  and  suggestions 
as  to  the  treatment  of  disease,  which  always 
characterize  the  productions  of  the  pen  of  Dr. 
Van  Buren." — Philadelphia  Medical  Times. 

"  The  most  attractive  feature  of  the  work 
is  the  plain,  common-sense  manner  in  which 
each  subject  is  treated.  The  author  has  laid  down  instructions  for  the  treatment,  medicinal  and  opera- 
tive, of  rectal  diseases  in  so  clear  and  lucid  style  as  that  any  practitioner  is  enabled  to  follow  it.  The 
large  and  successful  experience  of  the  distinguished  author  in  this  class  of  diseases  is  sufficient  of  itself  to 
warrant  the  high  character  of  the  book." — Nashville  Jou7-nal  of  Medicine  a?id  Sta-gery. 

We  have  thus  briefly  tried  to  give  the     known  to  the  profession  as  one  of  our  most  accom- 


reader  an  idea  of  the  scope  of  this  work  :  and  the 
work  is  a  good  one — as  good  as  either  Allingham's 
or  Curling's,  with  which  it  will  inevitably  be  com- 
pared. Indeed,  we  should  have  been  greatly  sur- 
prised if  any  work  from  the  pen  of  Dr.  Van  Buren 
had  not  been  a  good  one  ;  and  we  have  to  thank 
him  that  for  the  first  time  we  have  an  American 
text-book  on  this  subject  which  equals  those  that 
have  so  long  been  the  standards." — New  York  Med- 
ical yo2irnal. 

"  Mere  praise  of  a  book  like  this  would  be  super- 
fluous—almost impertinent.      The  author   is   well 


plished  surgeons  and  ablest  scientific  men.  Much 
is  expected  of  him  in  a  book  like  the  one  before  us, 
and  those  who  read  it  will  not  be  disappointed.  It 
will,  indeed,  be  widely  read,  and,  in  a  short  time, 
take  its  place  as  the  standard  American  authority." 
— .5'^.  Louis  Coui'ier  of  Medicine. 

"  Taken  as  a  whole,  the  book  is  one  of  the  most 
complete  and  reliable  ones  extant.  It  is  certainly 
the  best  of  any  similar  work  from  an  American  au- 
thor. It  is  handsomely  bound  and  illustrated,  and 
should  be  in  the  hands  of  every  practitioner  and 
student  of  medicine. " — Louisville  Medical  Llerald. 


REPORTS.     Bellevue  and  Charity  Hospital  Reports  for  1870, 

containing  valuable  contributions  from  Isaac  E.  Taylor,  M.  D.,  Austin 

Flint,  M.  D.,  Lewis  A.  Sayre,  M.  D,,  William  A.  Hammond,  M.  D.,  T. 

Gaillard  Thomas,  M.  D.,  Frank  H.  Hamilton,  M.  D.,  and  others. 

I  vol.,  8vo,  415  pp.     Cloth,  $4. 

''  These  institutions  are  the  most  important,  as     connected  with  tht^m  are  acknowledged  to  be  among 


regards  accommf)dations  for  patients  and  variety  of 
•ases  treated,  of  any  on  this  continent,  and  are  sur- 
passed by  but  few  in  the  world.     The  gentlemen 


the  first  in  tlioir  profession,  and  the  volume  is  an 
important  addition  to  the  professional  literature  o< 
this  country." — J'sychological  yoiirnal. 


D    APPLETON  <S-   CO:S  MEDICAL    WORKS.  5j 

THE  POSTHUMOUS  WORKS  OF  SIR  JAMES  YOUNG 

SIMPSON,  Eart.,  M.  D.     In  Three  Volumes. 

Volume    I. — Selected    Obstetrical    and    Gynecological   Works   of    Sir 

James  Y.  Simpson.     Edited  by  J.  Watt  Black,  M.  D. 

I  vol.,  8vo,  852  pp.     Cloth,  $3;  sheep,  $4. 

This  first  volume  contains  many  of  the  papers  reprinted  from  his  Obstetric  Memoirs  and  Con- 
tributions, and  also  his  Lecture  Notes,  now  published  for  the  first  time,  containing  the  substance 
of  the  practical  part  of  his  course  of  midwifery.  It  is  a  volume  of  great  interest  to  the  profession, 
and  a  fitting  memorial  of  its  renowned  and  talented  author. 

Volume  II. — Anesthesia,  Hospitalism,  etc.     Edited  by  Sir  Walter  Simp- 
son, Bart. 

"We  say  of  this,  as  of  the  first  volume,  that  it     may  be  picked  out  and  studied  with  pleasure  and 
should  find  a  place  on  the  table  of  every  practi-     profit." — Tlie  Lancet  {London). 
tioner ;  for,    although  it  is  patchwork,  each  piece 

I  vol.,  8vo,  560  pp.      Cloth,  $3  ;  sheep,  $4. 

Volume  III. — Diseases  of  Women.     Edited  by  Alexander  Simpson,  M.  D. 

I  vol,,  8vo,  789  pp.      Cloth,  $3;  sheep,  $4. 

One  of  the  best  works  on  the  subject  extant.     Of  inestimable  value  to  every  ph/siciah. 

ON    FOODS.      By    Edward    Smith,   M.  D.,    LL.  B.,   F.  R.  S, 

Fellow  of-the  Royal  College  of  Physicians  of  London,  etc.,  etc. 

I  vol.,  i2mo,  485  pp.     Cloth,  $1.75. 

•'  Since  the  issue  of  the  author's  work  on  '  Prac-  "  The  book  contains  a  series  of  diagrams,  dis- 

tical  Dietary,'  he  has  felt  the  want  of  another,  which  playing  the  effects  of  sleep  and  meals  on  pulsation 

would  embrace  all  the  generally  known  and  some  and  respiration,  and  of  various  kinds  of  food  on 

less  known  foods,  and  contain  the  latest  scientific  respiration,  which,  as  the  results  of  Dr.  Smith's  own 

knowledge  respecting  them.     The  present  volume  is  experiments,  possess  a  very  high  value.     We  have 

intended  to  meet  this  want,  and  will  be  found  use-  not  far  to  go  in  this  work  for  occasions  of  favorable 

ful   for   reference,    to   both    scientific   and   general  criticism  ;  they  occur  throughout,  but  are  perhaps 

readers.     The  author  extends  the  ordinary  view  of  most  apparent  in  those  parts  of  the  subject  with 

foods,  and  includes  water  and  air,  since  they  are  which   Dr.    Smith's  name  is  especially  linked." — • 

important  both  in  their  food  and  sanitary  aspects.  London  Exami?ier. 

A     HAND-BOOK     OF    CHEMICAL    TECHNOLOGY. 

By  Rudolph  Wagner,  Ph.  D.,  Professor  of  Chemical  Technology  at  the 
University  of  Wurtzburg.     Translated  and  edited,  from  the  eighth  German 
edition,  with  Extensive  Additions,  by  William  Crooks,  F.  R.  S. 
With  336  Illustrations,     i  vol.,  8vo,  761  pp.     Cloth,  $5. 

Under  the  head  of  Metallurgic  Chemistry,  the  latest  methods  of  preparing  iron,  cobalt,  nickel, 
copper,  copper-salts,  lead  and  tin  and  their  salts,  bismuth,  zinc,  zinc-salts,  cadmium,  antimony, 
arsenic,  mercury,  platinum,  silver,  gold,  manganates,  aluminum,  and  magnesium,  are  described. 
The  various  applications  of  the  voltaic  current  to  electro-metallurgy  follow  under  this  division. 
The  preparation  of  potash  and  soda-salts,  the  manufacture  of  sulphuric  acid,  and  the  recovery  of 
sulphur  from  soda  waste,  of  course  occupy  prominent  places  in  the  consideration  of  chemical  manu- 
factures. It  is  difhcult  to  overestimate  the  mercantile  value  of  Mond's  process,  as  well  as  the 
many  new  and  important  applications  of  bisulphide  of  carbon.  The  manufacture  of  soap  will  be 
found  to  include  much  detail.  The  technology  of  glass,  stone-ware,  limes,  and  mortars  will  pre- 
sent much  of  interest  to  the  builder  and  engineer.  The  technology  of  vegetable  fibers  has  been 
considered  to  include  the  preparation  of  flax,  hemp,  cotton,  as  well  as  paper-making ;  while  the 
application  of  vegetable  products  will  be  found  to  include  sugar-boiling,  wine-  and  beer-brewing, 
the  distillation  of  spirits,  the  baking  of  bread,  the  preparation  of  vinegar,  the  preservation  of  wood, 
etc. 

Dr.  Wagner  gives  much  information  in  reference  to  the  production  of  potash  from  sugar-resi- 
dues. The  use  of  baryta-salts  is  also  fully  described,  as  well  as  the  preparation  of  sugar  from 
beet-roots.  Tanning,  the  preservation  of  meat,  milk,  etc.,  the  preparation  of  phosphorus  and  ani- 
mal charcoal,  are  considered  as  belonging  to  the  technology  of  animal  products.  The  preparation 
of  materials  for  dyeing  has  necessarily  required  much  space  ;  while  the  final  sections  of  the  book 
have  been  devoted  to  the  technology  of  heating  and  illumination. 


32 

A 


D.  A  PPL  ETON 


CO:S  MEDICAL  WORKS. 


PRACTICAL    TREATISE     ON     THE     SURGICAL 

DISEASES  OF  THE  GENITO-URINARY  ORGANS,  including 
Syphilis.  Designed  as  a  Manual  for  Students  and  Practitioners.  With 
Engravings.  By  E.  L.  Keyes,  A.  M.,  M.  D.,  Professor  of  Genito-Urinary 
Surgery,  Syphilology,  and  Dermatology  in  Bellevue  Hospital  Medical  College. 
Being  a  revision  of  a  Treatise,  bearing  the  same  title,  by  Van  Buren  and 
Keyes,     Second  edition,  thoroughly  revised,  and  somewhat  enlarged. 

I  vol.,  8vo.     688  pp.     Cloth,  $5 ;  sheep,  $6. 

it  deals.  These  facts  are  largely  drawn  from 
the  extensive  and  varied  experience  of  the  au- 
thors. 

Many  important  branches  of  genito-urinary 
diseases,  as  the  cutaneous  maladies  of  the  penis 
and  scrotum,  receive  a  thorough  and  exhaustive 
treatment  that  the  professional  reader  will 
search  for  elsewhere  in  vain. 

The  subject  of  syphilis  is  included,  of  neces- 
sity, in  this  treatise.  Although  properly  be- 
longing to  the  department  of  Principles  of  Sur- 
gery, there  is  no  disease  falling  within  the  limits 
of  this  work  concerning  which  clear  and  cor- 
rect ideas  as  to  nature  and  treatment  will,  at 
the  present  time,  so  seriously  influence  success 
in  practice. 

The  present  edition  of  the  work  includes 
the  modern  operation  of  litholapaxy  which  is 
now  employed  in  the  place  of  lithotrity,  and  is 
elegantly  and  profusely  illustrated. 


' '  The  authors  '  appear  to  have  succeeded  admi- 
rably in  giving  to  the  world  an  exhaustive  and  re- 
liable treatise  on  this  important  class  of  diseases.'  " 
— Northwestern  Medical  and  Surgical  yournal. 

"  It  is  a  most  complete  digest  of  what  has  long 
been  known,  and  of  what  has  been  more  recently 
discovered,  in  the  field  of  syphilitic  and  genito-urin- 
ary disorders.  It  is,  perhaps,  not  all  exaggeration 
to  say  that  no  single  work  upon  the  same  subject 
has  yet  appeared,  in  this  or  any  foreign  language, 
which  is  superior  to  it.'" — Chicago  Medical  Exam- 
iner. 

' '  The  commanding  reputation  of  Dr.  Van  Buren 
in  this  specialty,  and  of  the  great  school  and  hos- 
pital from  which  he  has  drawn  his  clinical  materials, 
together  with  the  general  interest  which  attaches  to 
the  subject-matter  itself,  will,  we  trust,  lead  very 
many  of  those  for  whom  it  is  our  office  to  cater,  to 
possess  themselves  at  once  of  the  volume  and  form 
their  own  opinions  of  its  merit." — Atlanta  Medical 
and  Stirgical  Jotcrnal. 


Showing  Enlarged  Prostate  with  "Third  Lobe,"  through 
the  Base  of  which  a  False  Passage  has  been  made. 

This  work  is  really  a  compendium  of,  and  a 
book  of  reference  to,  all  modern  works  treating 
in  any  way  of  the  surgical  diseases  of  the  genito- 
urinary organs.  At  the  same  time,  no  other 
single  book  contains  so  large  an  array  oi  original 
facts  concerning  the  class  of  diseases  with  which 


A   MANUAL  OF    MIDWIFERY.     Including  the  Pathology 

of  Pregnancy  and  the  Puerperal  State.     By  Dr.  Carl  Schroeder,  Professor 
of  Midwifery  and  Director  of  the  Lying-in  Institution  in  the  University  of 
Erlangen.     Translated   from   the   third   German   edition   by  Charles   H. 
Carter,  B.  A.,  M.  D.,   B.  S.,   London,  Member  of  the  Royal  College  of 
Physicians,  London. 
With  Twenty-six  Engravings  on  Wood,     i  vol.,  8vo,  388  pp.     Cloth,  .$3.50;  sheep,  $4.50. 
"The  translator  feels  that  no'' apology  is  needed  in  offering  to  the  profession  a  translation  of 
Schroeder's  '  Manual  of  Midwifery.'     The  work  is  well  known  in  Germany,  and  extensively  used 
as  a  text-book;   it  has  already  reached  a  third  edition  within  the  short  space  of  two  years,  and  it 
is  hoped  that  the  present  translation  will  meet  the  want,  long  felt  in  this  country,  of  a  manual  of 
midwifery  embracing  the  latest  scientific  researches  on  the  subject." 


D.   APPLETON  &-   CO.'S  MEDICAL    WORKS. 


ZZ 


HOSPITALS  :  Their  History,  Organization,  and  Construction. 

Boylston  Prize-Essay  of  Harvard  University  for  1876.     By  W.  Gill  Wylie, 
M.  D.  I  vol.,  8vo,  240  pp.    Cloth,  $2.50. 


A    TREATISE     ON     CHEMISTRY.      By    H.    R.   Roscoe, 

F.  R.  S.,  and  C.  Schorlemmer,  F.  R.  S.,  Professors  of  Chemistry  in  the 
Victoria  University,  Owens  College,  Manchester.     Illustrated. 

INORGANIC  CHEMISTRY.  8vo.  Vol.  I  :  Non-Metallic  Elements.  $5. 
Vol.  II,  Part  I  :    Metals.    $3.     Vol.  II,  Part  II  :    Metals.     $3. 

ORGANIC  CHEMISTRY.  8vo.  Vol.  Ill,  Part  I  .  The  Chemistry  of  the 
Hydrocarbons  and  their  Derivatives.  $5.  Vol.  Ill,  Part  II,  com- 
pleting the  work  :  The  Chemistry  of  the  Hydrocarbons  and  their 
Derivatives.     $5. 

"  It  has  been  the  aim  of  the  authors,  in  writing  their  present  treatise,  to  place  before  the  read- 
er a  fairly  complete  and  yet  a  clear  and  succinct  statement  of  the  facts  of  Modern  Chemistry,  while 
at  the  same  time  entering  so  far  into  a  discussion  of  chemical  theory  as  the  size  of  the  work  and  the 
present  transition  state  of  the  science  will  permit. 

"  Special  attention  has  been  paid  to  the  accurate  description  of  the  more  important  processes 
in  technical  chemistry,  and  to  the  careful  representation  of  the  most  approved  forms  of  apparatus 
employed. 

"  Much  attention  has  likewise  been  given  to  the  representation  of  apparatus  adopted  for  lec- 
ture-room experiment,  and  the  numerous  new  illustrations  required  for  this  purpose  have  all  been 
taken  from  photographs  of  apparatus  actually  in  use." — Extract  from  Preface. 


Specimen  of  Illustration. 


"The  authors  are  evidently  bent  on  making 
their  book  the  finest  systematic  treatise  on  modern 
chemistry  in  the  EngHsh  language,  an  aim  in  which 
they  are  well  seconded  by  their  publishers,  who 
spare  neither  pains  nor  cost  in  illustrating  and 
otherwise  setting  forth  the  work  of  these  distin- 
guished chemists." — London  Athenaiim. 

"  It  is  difficult  to  praise  too  highly  the  selection 
of  materials  and  their  arrangement,  or  the  wealth 
of  illustrations  which  explain  and  adorn  the  text. 
In  its  woodcuts,  in  its  technological  details,  in  its 
historical  notices,  in  its  references  to  original 
memoirs,  and,  it  may  be  added,  in  its  clear  type, 
smooth  paper,  and  ample  margins,  the  volume  un- 
der review  presents  most  commendable  features. 
Whatever  tests  of  accuracy  as  to  figures  and  facts 
we  have  been  able  to  apply  have  been  satisfactorily 


met,  while  in  clearness  of  statement  this  volume 
leaves  nothing  to  be  desired.  Moreover,  it  is  most 
satisfactory  to  find  that  the  progress  of  this  valuable 
work  toward  completion  is  so  rapid  that  its  begin- 
ning will  not  have  become  antiquated  before  its  end 
has  been  reached — no  uncommon  occurrence  with 
elaborate  treatises  on  natural  science  subjects." — 
Londo7i  Academy. 

"  We  have  no  hesitation  in  saying  that  this  vol- 
ume fully  keeps  up  the  reputation  gained  by  those 
that  preceded  it.  There  is  the  same  masterly  hand- 
ling of  the  subject-matter  ;  the  same  diligent  care 
has  been  bestowed  on  hunting  up  all  the  old  history 
connected  with  each  product.  It  is  this  that  lends 
so  great  a  charm  to  the  whole  work,  and  makes  it 
very  much  more  than  a  mere  text-book." — Satur- 
day Review. 


34  D.   APPLETON  &=   CO.'S  MEDICAL    WORKS. 

THE     BRAIN    AND     ITS   FUNCTIONS.      By  J.   Luys, 

Physician  to  the  Hospice  de  la  Salpetriere. 

With  Illustrations.     i2mo.     Cloth,  $1.50. 

"  No  living:  physiologist    is    better  entitled   to  are  the  chapters  dealing  with  the  genesis  and  evolu- 
speak  with  authority  upon  the  structure  and  func-  tion  of  memory,  the  development  of  automatic  ac- 
tions of  the  brain  than   Dr.  Luys.     His  studies  on  tivity,  and  the  development  of  the  notion  of  person- 
the  anatomy  of  the  ner\-ous  system  are  acknowl-  ality." — Boston  Evefiing  Traveller. 
edged  to  be  the  fullest  and  most  systematic  ever  un- 
dertaken."-^-/.  James's  Gazette.  u  Dr.  Luys,  at  the  head  of  the  great  French  In- 

"  It  is  not  too  much  to  say  that  M,  Luys  has  gone  sane  Asylum,  is  one  of  the  most  eminent  and  sue- 
further  than  any  other  investigator  into  this  great  cessful  investigators  of  cerebral  science  now  living  ; 
field  of  study,  and  only  those  who  are  at  least  dimly  and  he  has  given  unquestionably  the  clearest  and 
aware  of  the  vast  changes  going  on  in  the  realm  of  most  interesting  brief  account  yet  made  of  the 
psychology  can  appreciate  the  importance  of  his  structure  and  operations  of  the  brain." — Popular 
revelations.     Particularly   interesting  and  valuable  Science  Mo7ithly. 

GENERAL      PHYSIOLOGY      OF      MUSCLES     AND 

NERVES,  By  Dr.  I.  Rosenthal,  Professor  of  Physiology  at  the  Univer- 
sity of  Erlangen. 

With  75  Woodcuts.     i2mo.     Cloth,  $1.50. 

"  Dr.  Rosenthal  claims  that  the  present  work  is  recondite  as  to  be  unprofitable  or  uninteresting  to 

the  '  first  attempt  at  a  connected  account  of  general  the  inquiring    general    reader." — New    York    Ob- 

physiology  of  muscles  and  nerves.'     This  being  the  server. 

case,  Dr.  Rosenthal  is  entitled  to  the  greatest  credit  >.  in  this  volume  an  attempt  is  made  to  give  a 

for  his  clear  and  accurate  presentation  of  the  ex-  connected  account  of    the  general  physiology  of 

perimental  data  upon   which  must  rest  all  future  muscles  and  nerves,  a  subject  which  has  never  be- 

knowledgeof  a  very  important  branch  of  medical  fore   had  so  thorough   an  exposition  in   any  text- 

and   electrical  science.     The  book  consists  of  317  book,  although  it  is  one  which  has  many  points  of 

pages,   with  seventy-five  woodcuts,  many  of  which  interest  for  evei7  cultivated  man   who  seeks  to  be 

represent   physiological  apparatus  devised  by   the  ^ell  informed  on  all  branches  of  the  science  of  life, 

author  or  by  his  friends,    Professor  Du   Bois-Rey-  This  work  sets  before  its  readers  all,  even  the  most 

mond  and  Helmholtz.     It  must  be  regarded  as  m-  intricate,  phases  of  its  subject  with  such  clearness  of 

dispensable  to  all  future  courses  of  medical  study."  expression  that  any  educated  person  though  not  a 

Aew  York  Herald.  specialist  can  comprehend  it." — New  Haven  Palla- 

"  Although  this  work  is  written  for  the  instruc-  dium, 
tion  of  students,  it  is  by  no  means  so  technical  and 

MEDICAL  AND  SURGICAL  ASPECTS  OF  IN-KNEE 

(Genu-Valgum)  :  Its  Relation  to  Rickets ;  its  Prevention ;  and  its  Treat- 
ment, with  or  without  Surgical  Operation.  By  W.  J.  Little,  M.  D.,  F.  R. 
C.  P.,  late  Senior  Physician  to  and  Lecturer  on  Medicine  at  the  London 
Hospital;  Visiting  Physician  to  the  Infant  Orphan  Asylum  at  Wanstead ; 
the  Earlswood  Asylum  for  Idiots ;  Founder  of  the  Royal  Orthopsedic  Hos- 
pital, etc.     Assisted  by  E.  Muirhead  Little,  M.  R.  C.  S. 

One  8vo  vol.,  containing  161  pages,  with  complete  Index,  and  illustrated  by  upward  of  50  Figures 

and  Diagrams.     Cloth,  $2. 

A     DICTIONARY     OF     MEDICINE,    including     General 

Pathology,  General  Therapeutics,  Hygiene,  and   the  Diseases   peculiar  to 

Woinen  and  Children.'    By  Various  Writers.     Edited  by  Richard  Quain, 

M.  D.,  F.  R.  S.,  Fellow  of  the  Royal  College  of  Physicians;   Member  of  the 

Senate  of  the  University  of  London  ;   Member  of  the  General  Council  of 

Medical  Education  and  Registration;  Consulting  Physician  to  the  Hospital 

for  Consumption  and  Diseases  of  the  Chest  at  Brompton,  etc. 

In  one  large  8vo  volume  of  1,834  pages,  and  138  Illustrations.     Half  morocco,  $8.     Sold  only  by 

sul^scription. 

This  work  is  primarily  a  Dictionary  of  Medicine,  in  which  the  several  diseases  are  fully  dis- 
cussed in  alphabetical  order.  The  description  of  each  includes  an  account  of  its  etiology  and  ana- 
tomical characters;   its  symptoms,  course,  duration,  and  termination;  its  diagnosis,  progncsis. 


D.   APPLETON  &-   CO.'S  MEDICAL    WORKS. 


35 


and,  lastly,  ils  treatment.  General  Pathology  comprehends  articles  on  the  origin,  characters,  and 
nature  of  disease. 

General  Therapeutics  includes  articles  on  the  several  classes  of  remedies,  their  modes  of  ac- 
tion, and  on  the  methods  of  their  use.  The  articles  devoted  to  the  subject  of  Hygiene  treat  of  the 
causes  and  prevention  of  disease,  of  the  agencies  and  laws  affecting  public  health,  of  the  means  of 
preserving  the  health  of  the  individual,  of  the  construction  and  management  of  hospitals,  and  of 
tiie  nursing  of  the  sick. 

Lastly,  the  diseases  peculiar  to  women  and  children  are  discussed  under  their  respective  head- 
ings, both  in  aggregate  and  in  detail. 

Among  the  leading  contributors,  whose  names  at  once  strike  the  reader  as  affording  a  guaran- 
tee of  the  value  of  their  contributions,  are  the  following : 


Allbutt,  T.  Clifford,  M.  A.,  M.  D. 

Barnes,  Robert,  M.  D. 

Bastian,  H.  Charlton,  M.  A.,  M.  D. 

BiNZ,  Carl,  M.  D. 

Bristowe,  J.  Syer,  M.  D. 

Brown-Sequard,  C.  E.,  M.  D.,  LL.  D. 

Brunton,  T.  Lauder,  M.  D.,  D.  Sc. 

Fayrer,  Sir  Joseph,  K.  C.  S.  L,  M.  D.,  LL.  D. 

Fox,  Tilbury,  M.  D. 

Galton,  Captain  Douglas,  R.  E.  (retired). 

Gowers,  W.  R.,  M.  D. 


Greenfield,  W.  S.,  M.  D. 
Jenner,  Sir  William,  Bart 
Lego,  J.  Wickham,  M.  D. 
Nightingale,  Florence. 
Paget,  Sir  James,  Bart. 
Parkes,  Edmund  A.,  M.  D. 
Pavy,  F.  W.,  M.D. 
Playfair,  W.  S.,  M.  D. 
Simon,  John,  C.  B.,  D.  C. 
Thompson,  Sir  Henry. 
Waters,  A.  T.  H.,  M.  D. 


K.  C.  B.,  M.D. 


L. 


Wells,  T.  Spencer. 


"  Not  only  is  the  work  a  Dictionary  of  Medicine 
in  its  fullest  sense  ;  but  it  is  so  encyclopedic  in  its 
scope  that  it  may  be  considered  a  condensed  review 
of  the  entire  field  of  practical  medicine.  Each  sub- 
ject is  marked  up  to  date  and  contains  in  a  nutshell 
the  accumulated  e.x:perience  of  the  leading  medical 
men  of  the  day.  As  a  volume  for  ready  reference 
and  careful  study,  it-will  be  found  of  immense  value 
to  the  general  practitioner  and  student." — Medical 
Record. 

"The  'Medical  Dictionary'  of  Dr.  Quain  is 
something  more  than  its  title  would  at  first  indicate. 
It  might  with  equal  propriety  be  called  an  encyclo- 
pjedia.  The  different  diseases  are  fully  discussed  in 
alphabetical  order.  The  description  of  each  in- 
cludes an  account  of  its  various  attributes,  often 
covering  several  pages.  Although  we  have  pos- 
sessed the  book  only  the  short  time  since  its  publica- 
tion, its  loss  would  leave  a  void  we  would  not  know 
how  to  fill." — Boston  Medical  atid  Surg.  Jourttal. 

"Although  a  volume  of  over  i,8oo  pages,  it  is 
truly  a  multunt  in  parvo,  and  will  be  found  of 
much  more  practical  utility  than  other  works  which 
might  be  named  extending  over  many  volumes. 
The  profession  of  this  country  are  under  obligations 
to  you  for  the  republication  of  the  work,  and  I  de- 
sire to  congratulate  you  on  the  excellence  of  the 
illustrations,  together  with  the  excellent  typograph- 
ical execution  in  all  respects." — Austin  Flint, 
M.  D. 

"  It  is  with  great  pleasure,  indeed,  that  we  an- 
nounce the  publication  in  this  country,  by  the  Ap- 
pletons,  of  this  most  superb  work.  Of  all  the 
medical  works  which  have  been,  and  which  will  be, 
published  this  year,  the  most  conspicuous  one  as 
embodying  learning  and  research — the  compilation 
into  one  great  volume,  as  it  were,  of  the  whole  sci- 
ence and  art  of  medicine — is  the  '  Dictionary  of 
Medicine '  of  Dr.  Quain.  Ziemen's  '  Practice  of 
Medicine '  and  Reynolds's  '  System  of  Medicine ' 
are  distinguished  works,  forming  compilations,  in 
the  single  department  of  practice,  of  the  labors  of 
many  very  eminent  physicians,  each  one  in  his  con- 
tributions presenting  the  results  of  his  own  observa- 
tions and  experiences,  as  well  as  those  of  the  inves- 
tigations of  others.  But  in  the  dictionaiy  of  Dr. 
Quain  there  are  embraced  not  merely  the  principles 
and  practice  of  medicine  in  the  contributions  by  the 
various  writers  of  eminence,  but  general  pathology, 
general  therapeutics,  hygiene,  diseases  of  women 
and  children,  etc." — Cincin?iati  Medical  News. 

"  Criticism  in  detail  we  have  not  attempted,  and 
this  is  in  the  main  because  there  is  not  much  room 


for  it.  Those  who  are  most  competent  to  pass  an 
opinion  will,  we  believe,  admit  that  Dr.  Quain  has 
carried  out  a  most  arduous  enterprise  with  great 
success.  His  '  Dictionaiy  of  Medicine '  embodies 
an  enormous  amount  of  information  in  a  most  ac- 
cessible form,  and  it  deserves  to  take  its  place  in  the 
library  of  every  medical  man  as  a  ready  guide  and 
safe  counselor.  Others,  too,  will  find  within  its 
pages  so  much  information  of  various  kinds  that  it 
can  not  fail  to  establish  itself  as  a  standard  work  of 
reference." — St.  Jameses  Budget. 

' '  Therefore  we  believe  that  as  a  whole  the  work 
will  admirably  fulfill  its  purpose  of  being  a  standard 
book  of  reference  until,  like  other  dictionaries  of 
progressive  science,  it  will  require  to  be  remodeled 
or  supplemented  to  keep  pace  with  advancing 
knowledge." — The  Lancet  {London). 

"I  think  '  Quain's  Dictionary  of  Medicine 'an 
excellent  work,  and  of  great  practical  use  for  eveiy- 
day  reference  by  the  physician." — Alexander  J.  C. 
Skene,  M.  D.,  Professor  of  the  Medical  atid  Surgi- 
cal Diseases  of  Women,  Long  Island  College  Hos- 
pital, Brooklytt,  N.  Y. 

"  I  regard  '  Quain's  Dictionary  of  Medicine '  the 
most  important,  because  most  useful,  publication  of 
its  kind  issued  from  the  medical  press  for  many  a 
year.  In  fact,  I  know  of  no  similar  work  that  can 
fitly  be  compared  with  it.  The  extraordinary  facili- 
ties Dr.  Quain  possesses,  in  the  choice  of  distin- 
guished collaborators,  have  been  applied  to  the  con- 
struction of  a  volume  whose  contents  are  so  clear 
and  compact,  yet  so  full,  that  the  hungriest  seeker 
after  the  latest  results  of  strictly  medical  research 
can  be  satisfied  at  one  sitting." — Alexander 
Hutchins,  M.  D. 

"  In  this  important  v/ork  the  editor  has  endeav- 
ored to  combine  two  features  or  purposes  :  in  the 
first  place,  to  offer  a  dictionary  of  the  technical 
words  used  in  medicine  and  the  collateral  sciences, 
and  also  to  present  a  treatise  on  systematic  medi- 
cine, in  which  the  separate  articles  on  diseases 
should  be  short  monographs  by  eminent  specialists 
in  the  several  branches  of  medical  and  surgical  sci- 
ence. Especially  for  the  latter  purpose,  he  secured 
the  aid  of  such  well-known  gentlemen  as  Charles 
Murchison,  John  Rose  Cormack,  Tilbury  Fox, 
Thomas  Ha)'den,  William  Aitken,  Charlton  Bas- 
tian, Brown-Sequard,  Sir  William  Jenner,  Eras- 
mus Wilson,  and  a  host  of  others.  By  their  aid  he 
may  fairly  be  said  to  have  attained  his  object  of 
'  bringing  together  the  latest  and  most  complete  in- 
formation, in  a  form  which  would  allow  of  ready 
and  easy  reference.' " — Med.  and  Surg.  Reporter. 


36 


D.   APPLETON  5-   CO:S  MEDICAL    WORKS. 


A  PRACTICAL  TREATISE  ON    THE    DISEASES   OF 

CHILDREN.  Third  American  from  the  eighth  German  edition.  Revised 
and  enlarged.  Illustrated  by  Six  Lithographic  Plates.  By  Alfred 
VoGEL,  M.  D.,  Professor  of  Clinical  Medicine  in  the  University  of  Dorpat, 
Russia.  Translated  and  edited  by  H.  Raphael,  M.  D.,  late  House  Sur- 
geon to  Bellevue  Hospital ;  Physician  to  the  Eastern  Dispensary  for  the 
Diseases  of  Children,  etc.,  etc. 

I  vol.,  8vo,  640  pp.     Cloth,  $4.50  ;  sheep,  $5.50. 

"'Vogel's  Treatise  on   Diseases  of   Children'  derived  from  the  possession  of  this  work." — Btcffato 

has  a  world-wide  reputation,  having  appeared  in  the  Medical  and  Surgical  Journal. 
Russian,  German,  Dutch,  and  EngUsh  languages. 

This  is  a  deserved  success,  for  it  is  a  book  admira-  "  This  is  indeed  a  valuable  addition  to  the  litera- 
bly  adapted  to  the  wants  both  of  the  practitioner  ture  of  Pediatrics.  ...  In  this  latest  edition  ('3d 
and  student.  The  present  edition  is  brought  well  American)  much  has  been  added  to  the  chapters  on 
up  to  the  present  state  of  pathological  knowledge,  Artificial  Nutrition,  a  subject  of  deep  interest  to  the 
it  is  complete  without  prohxity,  and  the  book  bears  practitioner,  on  Difficulties  of  Dentition,  and  on 
upon  its  pages  the  evidence  of  the  work  of  a  skillful  Nervous  Diseases  of  Children.  .  .  .  This  alone 
and  experienced  clinical  practitioner.  .  .  .  We  should  be  worth  the  price  of  the  book,  as  the  treat- 
would  most  heartily  commend  the  book  as  one  of  ment  of  diseases  of  children  is  too  much  after  the 
the  most  valuable  upon  the  subject,  and  indeed  few  stereotyped  fashion  of  the  last  century." — DaniePs 
physicians  can  afford  to  forego  the  advantages  to  be  Texas  Medical  yournal. 

THE    NEW    YORK    MEDICAL   JOURNAL:    A  Weekly 

Review  of  Medicine.     Edited  by  Frank  P.  Foster,  M.  D. 

The  New  York  Medical  Journal,  now  in  the  twenty-third  year  of  its  publication,  is  pub- 
lished every  Saturday,  each  number  containing  twenty-eight  large  double-columned  pages  of 
reading  matter.  By  reason  of  the  condensed  form  in  which  the  matter  is  arranged,  it  contains 
more  reading  matter  than  any  other  journal  of  its  class  in  the  United  States.  It  is  also  more 
freely  illustrated,  and  its  illustrations  are  generally  better  executed,  than  is  the  case  with  other 
weekly  journals. 

REASONS  WHY  PHYSICIANS  SHOULD  SUBSCRIBE  FOR  THE  JOURNAL. 

BECAUSE:  It  is  the  LEADING  JOURNAL  of  America,  and  contains  more  reading  matter 
than  any  other  journal  of  its  class. 

BECAUSE:  It  is  the  exponent  of  the  most  advanced  scientific  medical  thought. 

BECAUSE :  Its  contributors  are  among  the  most  learned  medical  men  of  this  country. 

BECAUSE:  Its  "Original  Articles"  are  the  results  of  scientific  observation  and  research,  and 
are  of  infinite  practical  value  to  the  general  practitioner. 

BECAUSE:  The  "Reports  on  the  Progress  of  Medicine,"  which  are  published  from  time  to 
time,  contain  the  most  recent  discoveries  in  the  various  departments  of  medicine,  and  are 
written  by  practitioners  especially  qualified  for  the  purpose. 

BECAUSE:  The  column  devoted  in  each  number  to  "Therapeutical  Notes"  contains  a  resume 
of  the  practical  application  of  the  most  recent  therapeutic  novelties. 

BECAUSE:  The  Society  Proceedings,  of  which  each  number  contains  one  or  more,  are  reports 
of  the  practical  experience  of  prominent  physicians  who  thus  give  to  the  profession  the  results 
of  certain  modes  of  treatment  in  given  cases. 

BECAUSE:  The  Editorial  Columns  are  controlled  only  by  the  desire  to  promote  the  welfare, 
honor,  and  advancement  of  the  science  of  medicine,  as  viewed  from  a  standpoint  looking  to 
the  best  interests  of  the  profession. 

BECAUSE:  Nothing  is  admitted  to  its  columns  that  has  not  some  bearing  on  medicine,  or  is  not 
possessed  of  some  practical  value. 

BECAUSE:  It  is  published  solely  in  the  interests  of  medicine,  and  for  the  upholding  of  the 
elevated  position  occupied  by  the  profession  of  America. 

The  volumes  begin  with  January  and  July  of  each  year.  Subscriptions  can  be  arranged  to 
begin  with  the  volume. 

Terms,  Payable  in  Advance:  One  Year,  $5.00;  Six  Months,  $2.50;  Single  Copy,  10 
cents.     (No  subscriptions  received  for  less  than  six  months. )     Bindhig  Cases,  Cloth,  50  cents. 

THE  POPULAR  SCIENCE  MONTHLY  and  TMl':  NEW  YORK  MEDICAL  JOUR- 
NAL to  the  same  address,  $9.00  per  annum  (full  price,  $10.00),  payable  in  advance. 


D.  APPLETON  S-  CO:S  MEDICAL   WORKS.  t^j 

PARALYSES:   CEREBRAL,   BULBAR,  AND   SPINAL. 

A  Manual  of  Diagnosis  for  Students  and  Practitioners.     By  H.  Charlton 

Bastian,  M.  a.,  M.  D.,  F.  R.  S.  ;  Fellow  of  the  Royal  College  of  Physicians; 

Examiner  in  Medicine  at  the  Royal  College  of  Physicians  ;  Professor  of 

Clinical  Medicine  and  of    Pathological   Anatomy  in    University  College, 

London,  etc. 

With  136  Illustrations.     Small  8vo,  671  pages.     Cloth,  $4.50. 

"  The  work  is  designed  to  facilitate  diagnosis  of  "  This  is  '  a  manual  of  diagnosis  for  students 

the  various  forms  of  paralysis.   .   .  .  The  book  sup-  and  practitioners,'  and  as  a  special  work  on  the  di- 

plies  a  want  long  felt ;  to  come  from  this  celebrated  agnosis  on  localization  of  a  paralyzmg  lesion  we  do 

author   makes  it  much   more  vaXnahXe."— Buffalo  not  know  of  its  equal  in  any  language."— Fir^zwzfl 

Medical  and  Surgical  Jotirnal.  Medical  Monthly. 

"  We  deem  the  work  to  be  one  of  immense  value  ,,^^  ^^^   strongly   recommend    Dr.    Bastian's 

which  must  add  greatly  to  its  author's  already  large  ^^^y.  ^^  ^-^^  student  and  practitioner  as  a  monument 

reputation,  and  we  are  heartily  glad  to  see  it  repro-  ^j  learning  exceedingly  well  put  together."— Z,a«c^/. 
duced  by  an  American  publishing  ho\is&."— Medical 

Press  oj  Western  New  York.  , ,  p^^.  diagnosis  Bastian's  work  will  take  the  high- 

"  Throughout  the  work  the  author's  mastery  of  est  rank.     It  is  remarkable  for  its  philosophical  tone 

the  subject  is  constantly  apparent,  and  it  must  take  and  for  the  author's  critical  comments  on  numerous 

rank  as  without  a  superior  in  its  special  department."  obscure  problems  on  n&xxoXo^ .''—American  Jour- 

— Medical  and  Surgical  Reporter.  nal  of  the  Medical  Sciences. 

ELEMENTS  OF  PRACTICAL  MEDICINE.  By  Alfred 
H.  Carter,  M.  D.,  Member  of  the  Royal  College  of  Physicians,  London  ; 
Physician  to  the  Queen's  Hospital,  Birmingham,  etc. 

Third  edition,  revised  and  enlarged,     i  vol.,  i2mo,  427  pages.     Cloth,  $3.00. 

"Although  this  work  does  not  profess  to  be  a  wisely,  perhaps,  since  we  know  so  little  about  it ; 

complete  treatise  on  the  practice  of  medicine,  it  is  and  of  that  other  almost   unknown   quantity   in 

too  full  to  be  called  a  compend  ;  it  is  rather  an  in-  medicine,  scrofula,  the  author  has  with  equal  pru- 

troduction  to  the  more  exhaustive  study  embodied  dence  abstained   from  saying   much.     He  admits 

in  the  larger  text-books.     An  idea  of  the  degree  to  such  a  condition  as  scrofulosis,  but  thinks  it  has  no 

which  condensation  has  been  carried  in  it  can  be  necessary  connection  with  tuberculosis.      He  is  a 

gathered  from  the  statement  that  but  twenty-one  believer  in  the  germ-theory  of  disease,  and  speaks 

pages  are  occupied  with  the  diseases  of  the  circula-  of  Koch's  investigations  and  discoveries  as  very  im- 

tory  system.    If  the  reader  gets  the  impression  that  portant,  to  him  almost  conclusive, 
the  physical  signs  are  given  somewhat  too  meager-  "Notwithstanding  the  condensed   make-up  of 

ly,  it  is  to  be  said  that,  by  way  of  compensation,  the  book,  it  is  quite  comprehensive,  including  even 

the  symptomatology  in  general  is  considered  with  cutaneous  and  venereal  diseases.    It  contains  much 

admirable  perspicuity  and  good  judgment.  valuable  information,  and  we  may  add  that  it  is 

"  Leucocythffimia  is  dismissed  with  one  page —  very  readable." — New  York  Medical  yoiirnal. 

THE  MINERAL  SPRINGS  OF  THE  UNITED  STATES 

AND    CANADA,  with  Analysis  and   Notes   on   the    Prominent    Spas    of 

Europe  and  a  List  of  Sea-side  Resorts.     An  enlarged  and  revised  edition 

By  George  E.  Walton,  M.  D.,  Lecturer  on  Materia  Medica  in  the  Miami 

Medical  College,  Cincinnati. 

Second  edition,  revised  and  enlarged.     I  vol.,  i2mo,  414  pp.     With  Maps.     $2. 

The  author  has  given  the  analysis  of  all  the  springs  in  this  country  and  those  of  the  principal 
European  spas,  reduced  to  a  uniform  standard  of  one  wine-pint,  so  that  they  may  readily  be  com- 
pared. He  has  arranged  the  springs  of  America  and  Europe  in  seven  distinct  classes,  and  de- 
scribed the  diseases  to  which  mineral  waters  are  adapted,  with  references  to  the  class  of  waters 
applicable  to  the  treatment ;  and  the  peculiar  characteristics  of  each  spring  as  near  as  known  are 
given — also  the  location,  mode  of  access,  and  post-office  address  of  every  spring  are  mentioned. 
In  addition,  he  has  described  the  various  kinds  of  baths  and  the  appropriate  use  of  them  in  the 
treatment  of  disease. 

"  Precise  and  comprehensive,  presenting  not  only     use  as  intelligently  and  beneficially  as  they  can  other 
reliable  analysis  of  the  waters,  but  their  therapeutic     valuable  alterative  agents." — Sanitarian. 
value,  so  that  physicians  can  hereafter  advise  their 


D.   APPLE  TON  &-   CO:S  MEDICAL    WORKS. 


DISEASES  OF  MEMORY  :  An  Essay  in  the  Positive  Psy- 
chology. By  Th.  Ribot,  Author  of  "  Heredity,"  etc.  Translated  from  the 
French  by  William  Huntington  Smith. 

i2mo.     Cloth,  $1.50. 


"Not  merely  to  scientific,  but  to  all  thinking 
men,  this  volume  will  prove  Intensely  interesting." 
— New  York  Observer. 

"  M.  Ribot  has  bestowed  the  most  painstaking 
attention  upon  his  theme,  and  numerous  examples 
of  the  conditions  considered  greatly  increase  the 
value  and  interest  of  the  volume." — P/iiladelphia 
North  American. 

"'Memorj','  says  M.  Ribot,  'is  a  general  func- 
tion of  the  nervous  system.  It  is  based  upon  the 
faculty  posses«!ed  by  the  nervous  elements  of  con- 
serving a  received  modification,  and  of  forming  as- 
sociations.' And  again  :  '  Memory  is  a  biological 
fact.  A  rich  and  extensive  memory  is  not  a  collec- 
tion of  impressions,  but  an  accumulation  of  dynam- 


ical associations,  very  stable  and  very  responsive  to 
proper  stimuli.  .  .  .  The  brain  is  like  a  laboratory 
full  of  movement  where  thousands  of  operations  are 
going  on  all  at  once.  Unconscious  cerebration,  not 
being  subject  to  restrictions  of  time,  operating,  so  to 
speak,  only  in  space,  may  act  in  several  directions 
at  the  same  moment.  Consciousness  is  the  narrow 
gate  through  which  a  very  small  part  of  all  this 
work  is  able  to  reach  us.'  M.  Ribot  thus  reduces 
diseases  of  memory  to  law,  and  his  treatise  is  of  ex- 
traordinary interest." — Philadelphia  Press. 

"  It  is  not  too  much  to  say  that  in  no  single  work 
have  so  many  curious  cases  been  brought  together 
and  interpreted  in  a  scientific  manner." — Boston 
Eveni?ig  Traveller. 


A   TREATISE    ON    INSANITY,  in   its   Medical  Relations. 

By  William  A.  Hammond,  M.  D.,  Surgeon-General  U.  S.  Army  (retired 
list) ;  Professor  of  Diseases  of  the  Mind  and  Nervous  System,  in  the  New 
York  Post-Graduate  Medical  School ;  President  of  the  American  Neuro- 
logical Association,  etc. 

I  vol.,  8vo,  767  pp.      Cloth,  $5;  sheep,  $6. 

In  this  work  the  author  has  not  only  considered  the  subject  of  Insanity,  but  has  prefixed  that 
division  of  his  work  with  a  general  view  of  the  mind  and  the  several  categories  of  mental  faculties, 
and  a  full  account  of  the  various  causes  that  exercise  an  influence  over  mental  derangement,  such 
as  habit,  age,  sex,  hereditary  tendency,  constitution,  temperament,  instinct,  sleep,  dreams,  and 
many  other  factors. 

Insanity,  it  is  believed,  is  in  this  volume  brought  before  the  reader  in  an  original  manner,  and 
with  a  degree  of  thoroughness  which  can  not  but  lead  to  important  results  in  the  study  of  psycho- 
logical medicine.  Those  forms  which  have  only  been  incidentally  alluded  to  or  entirely  disregard- 
ed in  the  text-books  hitherto  published  are  here  shown  to  be  of  the  greatest  interest  to  the  general 
practitioner  and  student  of  mental  science,  both  from  a  normal  and  abnormal  stand-point.  To  a 
great  extent  the  work  relates  to  those  species  of  mental  derangement  which  are  not  seen  within 
asylum  walls,  and  which,  therefore,  are  of  special  importance  to  the  non-asylum  physician. 
Moreover,  it  points  out  the  symptoms  of  Insanity  in  its  first  stages,  during  which  there  is  most 
hope  of  successful  medical  treatment,  and  before  the  idea  of  an  asylum  has  occurred  to  the  patient's 
friends. 


"  We  believe  we  may  fairly  say  that  the  volume 
is  a  sound  and  practical  treatise  on  the  subject  with 
which  it  deals  ;  contains  a  great  deal  of  information 
carefully  selected  and  put  together  in  a  pleasant  and 
readable  form  ;  and,  emanating,  as  it  does,  from  an 
author  whose  previous  works  have  met  with  a  most 
favorable  reception,  will,  we  have  little  doubt,  obtain 
a  wide  circulation." — The  Dublin  Journal  of  Medi- 
cal Science. 

"...  The  times  are  ripe  for  a  new  work  on  in- 
sanity, and  Dr.  Hammond's  great  work  will  serve 
hereafter  to  mark  an  era  in  the  history  of  American 
psychiatry.  It  should  be  in  the  hands  of  every 
physician  who  wishes  to  have  an  understanding  of 
the  present  status  of  this  advancing  science.  Who 
begins  to  read  it  will  need  no  urging  to  continue  ; 
he  will  ba  carried  along  irresistibly.  We  unhesitat- 
ingly pronounce  it  one  of  the  best  works  on  insan- 
ity which  has  yet  appeared  in  the  English  language." 
— American  yournal  0/  the  Medical  Sciotces. 

"  Dr.  Hammond  is  a  bold  and  strong  writer,  has 
given  much  study  to  his  subject,  and  expresses  him- 
self so  as  to  be  understood  by  the  reader,  even  if  the 
latter  does  not  coincide  with  him.  We  like  the  book 
very  much,  and  consider  it  a  valuable  addition  to  the 
literature  of   insanity.     We   have  no  hesitancy  in 


commending  the  book  to  the  medical  profession,  as 
it  is  to  them  it  is  specially  addressed." — Therapeutic 
Gazette. 

"  Dr.  Hammond  has  added  another  great  work 
to  the  long  list  of  valuable  publications  which  have 
placed  him  among  the  foremost  neurologists  and 
alienists  of  America  ;  and  we  predict  for  this  volume 
the  happy  fortune  of  its  predecessors — a  rapid  jour- 
ney through  paying  editions.  We  are  sorry  that  our 
limits  will  not  permit  of  an  analysis  of  this  work, 
the  best  text-book  on  insanity  that  has  yet  appeared." 
—  7'he  Polyclitzic. 

' '  We  are  ready  to  welcome  the  present  volume 
as  the  most  lucid,  comprehensive,  and  practical  ex- 
position on  insanity  that  has  been  issued  in  this 
country  by  an  American  alienist,  and  furthermore, 
it  is  the  most  instructive  and  assimilable  that  can  be 
placed  at  present  in  the  hands  of  the  student  unini- 
tiated in  psychiatry.  The  instruction  contained 
within  its  pages  is  a  food  thoroughly  prepared  for 
mental  digestion  :  rich  in  the  condiments  that  stimu- 
late the  appetite  for  learning,  and  substantial  in  the 
more  solid  elements  that  enlarge  and  strengthen  the 
intellect." — New  Orleans  Medical  and  Surgical 
Journal. 


D.   APPLETON  <&-  CO:S  MEDICAL   WORKS.  oA 

THE  POPULAR  SCIENCE  MONTHLY.    Established  by 
E.  L-  YouMANS.     Edited  by  W.  J.  Youmans. 

The  volumes  begin  in  May  and  November  of  each  year.     Subscriptions  may  begin 
at  any  time.     Terms,  $5.00  per  annum;  single  numbers,  50  cents. 

"The   Popular   Science   Monthly"   and    "New  York   Medical   Journal"  to  one 
address,  $9.00  per  annum  (full  price,  $10.00),  payable  in  advance. 

"The  Popular  Science  Monthly"  will  contain  articles  by  well-known  writers  on  all 
subjects  of  practical  interest.  Its  range  of  topics,  which  is  widening  with  the  advance 
of  science,  includes : 

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Domestic  and  Social  Economy.  Practical  Life. 

Education.  The  Development  of  the  Race. 

Religion  as  it  is  related  to  Science.  Food-products  and  Agriculture. 

Ethics,  based  on  Scientific  Principles.  Natural  History;   Scientific  Exploration. 

Sanitary  Conditions;     Hygiene;     the  Pre-  Discovery;  Experimental  Science, 

vention  of  Disease.  The  Practical  Arts. 
The  Science  of  Living. 

Contains  Illustrated  Articles ;   Portraits ;  Biographical  Sketches. 

It  records  the  advance  made  in  every  branch  of  science. 

It  is  not  technical ;  it  is  intended  for  non-scientific  as  well  as  scientific  readers,  for 
all  persons  of  intelligence. 

No  magazine  in  the  world  contains  papers  of  a  more  instructive  and  at  the  same  time 
of  a  more  interesting  character. 

"  This  is  one  of  the  very  best  periodicals  of  its  to  persons  of  literary  tastes  who  have  neither  time 
kind  published  in  the  world.  Its  corps  of  contribu-  nor  opportunity  to  prosecute  special  scientific  re- 
tors  comprise  many  of  the  ablest  minds  known  to  searches,  but  who,  nevertheless,  wish  to  have  a  cor- 
science  and  literature." — Atnerican  Medical  you7'-  rect  understanding  of  what  is  being  done  by  others 
nal  (St.  Louis).  in  the  various  departments  of  science." — Louisiana 

<i  TVT        ■     ,.-ii      i   J     ..  J-  -ii-   ..I.-        you}-nal  0/ Educatio?i. 

"  No  scientific  student  can  dispense  with  this     -^  -^ 

monthly,  and  it  is  difficult  to  understand  how  any  "  A  journal  of  eminent  value  to   the  cause  of 

one  making  literary  pretensions  fails  to  become  a  popular  education   in   this  country." — New   York 

regfular  reader  of  this  journal.      '  The  Popular  Sci-  Tribune. 

ence  Monthly'  meets  a  want  of  the  medical  profes-  ,,  „            ,      ..,.,,      ,      , ,  ,         ,,  .       , 

sion  not  otherwise  met.     It  keeps  full  pace  with  the  ^,     Every  physician  s  table  should  bear  this  yalu- 

progress  of  the  times  in  all  the  departments  of  sci-  ^^1^  monthly,  which  we  believe  to  be  one  of  the 

entific  pursuit. "-  Virginia  Medical  Monthly.  ^o^t  interesting  and  instruc  ive  of  the  periodicals 

now  published,  and  one  which  is  destined  to  play  a 

"  Outside  of  medical  journals,  there  is  no  peri-  large  part  in  the  mental  development  of  the  laity  of 

odical  published  in  America  as  well  worthy  of  being  this  country." — Canadian  Journal  0/ Medical  Sci- 

placed  upon  the  physician's  library-table  and  regu-  ence. 

larly  read  by  him  as  "  The  Popular  Science  Month-  ,,t-..                •       •           ^,    -^         •  i_.^  •         u    /• 

ly.'  "-.5-/.  Louis  Clinical  Record.  .,        This  magazine  is  worth  its  weight  in  gold,  for 

its  service  in   educating  the  people.  — American 

"  '  The  Popular  Science  Monthly  '  is  invaluable  Journal  of  Educatio7i  (St.  Louis). 

DISEASES    OF    THE    OVARIES:    Their    Diagnosis    and 

Treatment.     By  T.  Spencer  Wells,  Fellow  and  Member  of  Council  of 

the  Royal  College  of  Surgeons  of  England,  etc.,  etc. 

I  vol.,  8vo,  478  pp.      Illustrated.     Cloth,  $4.50. 

In  1865  the  author  issued  a  volume  containing  reports  of  one  hundred  and  fourteen  cases  of 
Ovariotomy,  which  was  little  more  than  a  simple  record  of  facts.  The  book  was  soon  out  of  print, 
and,  though  repeatedly  asked  for  a  new  edition,  the  author  was  unable  to  do  more  than  prepare 
papers  for  the  Royal  Medical  and  Chiruvgical  Society,  as  series  after  series  of  a  hundred  cases  ac- 
cumulated. On  the  completion  of  five  hundred  cases,  he  embodied  the  results  in  the  present  vol- 
ume, an  entirely  new  work,  for  the  student  and  practitioner,  and  trusts  it  may  prove  acceptable  to 
them  and  useful  to  suffering  women. 


40 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


LECTURES   ON    THE    PRINCIPLES   OF    SURGERY. 

Delivered  at  the  Bellevue  Hospital  Medical  College.     By  the  late  W.  H. 
Van  Buren,  M.  D.,  LL.  D,     Edited  by  Dr.  Lewis  A.  Stimson. 

I  vol.,  8vo,  5S8  pages.     Cloth,  $4.00  ;   sheep,  $5.00. 


"  The  name  of  the  author  is  enoug;h.  The  book 
will  sell.  The  lectures  are  good." — Denver  Medi- 
cal Ti?nes. 

"If  we  are  to  judge  of  the  interesting  style  by 
the  mere  reading  of  these  lectures,  how  greatly  they 
must  have  been  appreciated  by  those  who  heard 
them  by  the  teacher  !  There  is  nothing  dry  or  prosy 
in  them.  The  illustrations  of  principles  are  drawn 
from  the  clinical  material  of  the  teacher,  and  are 
always  fresh  and  a  propos.  Past  and  present  theo- 
ries are  compared  in  such  a  way  as  to  g^ive  the  stu- 
dent an  interest  in  the  work  of  older  pathologists, 
and  to  point  out  progress  made,  without  wearying 


him  with  a  dry  narration  at  a  time  when  he  is  not 
able  to  comprehend  the  underlying  philosophy. 

"  Dr.  Van  Buren's  popularity  as  a  teacher  can 
be  easily  understood  from  a  study  of  this  volume. 
His  manner  is  vivacious,  his  matter  select,  and  his 
fullness  of  knowledge  easily  discernible.  He  writes 
like  one  in  authority,  full  of  enthusiasm,  and  pos- 
sessed of  the  skill  of  imparting  to  students  just  that 
sort  of  knowledge  best  suited  to  their  future  intel- 
lectual growth. 

"The  work  is  handsomely  printed,  with  full- 
faced,  clear  type  and  leaded  lines,  and  is  in  every 
way  a  credit  to  the  publishers." — North  Carolina- 
Medical  jfonrnal. 


OSTEOTOMY  AND  OSTEOCLASIS,  for  the  Correction  of 

Deformities  of  the  Lower  Limbs.     By  Charles  T.  Poore,  M.  D.,  Surgeon 
to  St.  Mary's  Free  Hospital  for  Children,  New  York. 

I  vol.,  8vo,  202  pages,  with  50  Illustrations.     Cloth,  $2.50. 


"This  handsome  and  carefully-prepared  mono- 
graph treats  of  osteotomy  as  applied  to  the  repair 
of  genu  valgum,  genu  varum,  anchylosis  of  the 
knee-joint,  deformities  of  the  hip-joint,  and  for 
curves  of  the  tibia.  The  author  has  enjoyed  large 
opportunities  to  study  these  special  malformations 
in  the  hospitals  to  which  he  is  attached,  and  de- 
scribes the  operations  from  an  ample  observation. 
Quite  a  number  of  well-engraved  illustrations  add 
to  the  value  of  the  volume,  and  an  exhaustive  bib- 
liography appended  enables  the  reader  to  pursue 
any  topic  in  which  he  may  be  interested  into  the 
productions  of  other  writers." — Medical  and  Sur- 
gical Reporter. 

"  Dr.  Poore,  who  has  already  become  so  well 
known  by  journal  articles  on  bone  surgery,  has  con- 


densed his  experience  in  the  work  before  us.  He 
has  succeeded  in  doing  this  in  a  very  satisfactory 
way.  We  can  not  too  strongly  commend  the  clear 
and  succinct  manner  in  which  the  author  weighs 
the  indications  for  treatment  in  particular  cases. 
In  so  doing  he  shows  a  knowledge  of  his  subject 
which  is  as  extensive  as  it  is  profound,  and  no  one 
at  all  interested  in  orthopedy  can  read  his  conclu- 
sions without  profit.  His  own  cases,  which  are 
carefully  reported,  are  valuable  additions  to  the  lit- 
erature of  the  subject.  These,  together  with  oth- 
ers, which  are  only  summarized,  contain  so  much 
practical  information  and  sound  surgery  that  they 
give  a  special  value  to  the  work,  altogether  inde- 
pendent of  its  other  excellences.  It  is  a  good  book 
in  every  way,  and  we  congratulate  the  author  ac« 
cordingly." — Medical  Record. 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


41 


TREATISE    ON    BRAIN-EXHAUSTION,   with   some 

Preliminary  Considerations  on  Cerebral  Dynamics.  By  J.  Leonard  Corn- 
ing, M.  D.,  formerly  Resident  Assistant  Physician  to  the  Hudson  River 
State  Hospital  for  the  Insane  ;  Member  of  the  Medical  Society  of  the 
County  of  New  York,  of  the  Physicians'  Mutual  Aid  Association,  of  the 
New  York  Neurological  Society,  of  the  New  York  Medico-Legal  Society, 
of  the  Society  of  Medical  Jurisprudence  ;  Physician  to  the  New  York  Neu- 
rological Infirmary,  etc.  ;  Member  of  the  New  York  Academy  of  Medicine. 

Crown  8vo.     Cloth,  $2.00. 


"  Dr.  Coming's  neat  little  volume  has  the  merit 
of  being  highly  suggestive,  and,  besides,  is  better 
adapted  to  popular  reading  than  any  other  profes- 
sional work  on  the  subject  that  we  know  of." — Pa- 
cific Medical  a?td  Surgical  yournal. 

"  This  is  a  capital  little  work  on  the  subject 
upon  which  it  treats,  and  the  author  has  presented, 
from  as  real  a  scientific  stand-point  as  possible,  a 
group  of  symptoms,  the  importance  of  which  is 
sufficiently  evident.  To  f uUy  comprehend  the  ideas 
as  presented  by  the  author,  the  whole  book  should 
be  read  ;  and,  as  it  consists  of  only  234  pages,  the 
task  would  not  be  a  severe  or  tedious  one,  and  the 
information  or  knowledge  obtained  would  be  much 
more  than  equivalent  for  the  time  spent  and  cost 
of  book  included.  Literary  men  and  women  would 
do  well  to  procure  it." — Therapeutic  Gazette. 


"  This  book  belongs  to  a  class  that  is  more  and 
more  demanded  by  the  cultured  intelligence  of  the 
period  in  which  we  live.  Dr.  Corning  may  be 
ranked  with  Hammond,  Beard,  Mitchell,  and 
Crothers,  of  this  country,  and  with  Winslow,  An- 
stie,  Thompson,  and  more  recent  authors  of  Great 
Britain,  in  discussing  the  problems  of  mental  dis- 
turbance, in  a  style  that  makes  it  not  only  profit- 
able but  attractive  reading  for  the  student  of  psy- 
chology. The  author  has  divided  the  work  into 
short  chapters,  under  general  headings,  which  are 
again  subdivided  into  topics,  that  are  paragraphed 
in  a  concise  and  definite  form,  which  at  once  strikes 
the  careful  reader  as  characteristic  of  a  method  that 
is  terse,  concise,  and  readily  apprehended.  There 
are  twenty-eight  of  these  pithy  chapters,  which  no 
student  of  mental  diseases  can  fail  to  read  without 
loss." — American  Psychological  Journal. 


PRACTICAL  MANUAL  OF   DISEASES   OF  WOMEN 

AND  UTERINE  THERAPEUTICS.  For  Students  and  Practitioners. 
By  H.  Macnaughton  Jones,  M.  D.,  F.  R.  C.  S.  I.  and  E.,  Examiner  in 
Obstetrics,  Royal  University  of  Ireland  ;  Fellow  of  the  Academy  of  Medi- 
cine in  Ireland  ;  and  of  the  Obstetrical  Society  of  London,  etc. 

I  vol.,  i2mo.     410  pages.     1S8  Illustrations.     Cloth,  $3.00. 


"  As  a  concise,  well-written,  useful  manual,  we 
consider  this  one  of  the  best  we  have  ever  seen. 
The  author,  in  the  preface,  tells  us  that  '  this  book 
is  simply  intended  as  a  practitioner's  and  student's 
manual.  I  have  endeavored  to  make  it  as  practical 
in  its  teachings  as  possible.'  The  style  is  pleasant 
to  peruse.  The  author  expresses  his  ideas  in  a  clear 
manner,  and  it  is  well  up  with  the  approved  meth- 
ods and  treatment  of  the  day.  It  is  well  illustrated, 
and  due  credit  is  given  to  American  g}-njecologists 
for  work  done.  It  is  a  good  book,  well  printed  in 
good,  large  type,  and  well  bound." — New  E^igland 
Medical  Monthly. 

"  It  is  seldom  that  we  see  a  book  so  completely 
fill  its  avowed  mission  as  does  the  one  before  us. 
It  is  practical  from  beginning  to  end,  and  can  not 
fail  to  be  appreciated  by  the  readers  for  whom  it  is 
intended.  The  author's  style  is  terse  and  perspicu- 
ous, and  he  has  the  enviable  faculty  of  giving  the 
learner  a  clear  insight  of  his  methods  and  reasons 
for  treatment.  Prepared  for  the  practitioner,  this 
little  work  deals  only  with  his  every-day  wants  in 
ordinary  family  practice.  Every  one  is  compelled 
to  treat  uterine  disease  who  does  any  general  busi- 
ness whatever,  and  should  become  acquainted  with 
the  minor  operations  thereto  pertaining.    The  book 


before  us  covers  this  ground  completely,  and  we 
have  nothing  to  offer  in  the  way  of  criticism." — 
Medical  Record. 

"  The  manual  before  us  is  not  the  work  of  a  spe- 
cialist— using  this  term  in  a  narrow  sense — but  of 
an  author  already  favorably  known  to  the  students 
of  current  medical  literature  by  various  and  com- 
prehensive works  upon  other  branches  of  his  profes- 
sion. Nor  is  it,  on  the  other  hand,  the  work  of  an 
amateur  or  merely  ingenious  collaborateur,  for  Dr. 
Macnaughton  Jones's  gynaecological  experience  in 
connection  with  the  Cork  Hospital  for  Women  and 
the  Cork  Maternity  was  such  as  fairly  entitles  him 
to  speak  authoritatively  upon  the  subjects  with 
which  it  deals.  But,  after  so  many  works  by  avowed 
specialists,  we  are  glad  to  welcome  one  upon  Gynse- 
cology  by  an  author  whose  opportunities  and  energy 
have  enabled  him  to  master  the  details  of  so  many 
branches  of  medicine.  We  are  glad  also  to  be  able 
to  state  that  his  work  compares  very  favorably  with 
others  of  the  same  kind,  and  that  it  does  admirably 
fulfill  the  purposes  with  which  it  was  written — '  as 
a  safe  guide  in  practice  to  the  practitioner,  and  an 
assistance  in  the  study  of  this  branch  of  his  profes- 
sion to  the  student.'" — Dublin  Journal 0/ Medical 
Science. 


42 


D.  APPLE  TON  &-   CO:S  MEDICAL    WORKS. 


A  HAND-BOOK  OF  THE   DISEASES  OF  THE  EYE, 

AND  THEIR  TREATMENT.  By  Henry  R.  Swanzy,  A.  M.,  M.  B., 
F.  R.  C.  S.  I.,  Surgeon  to  the  National  Eye  and  Ear  Infirmary ;  Ophthalmic 
Surgeon  to  the  Adelaide  Hospital,  Dublin. 


Crown  8vo,  437  pages. 


With  122   Illustralions,  and    Holmgren's  Tests   for   Color-Blindness. 
Cloth,  $3.00. 


"  Thoug-h,  amid  the  numerous  recent  text-books 
on  eye-diseases,  there  would  appear  to  be  little 
room  or  necessity  for  another,  we  must  admit  that 
this  one  justifies  its  presence,  by  its  admirable  type, 
illustrations,  and  dress,  by  its  clear  wording,  and, 
above  all,  by  the  vast  amount  of  varied  matter 
which  it  embraces  within  the  relatively  small  com- 
pass of  some  four  hundred  pages.  The  author  has 
omitted — and,  in  our  opinion,  with  perfect  wis- 
dom— the  usual  collection  of  indifferent,  second- 
hand ophthalmoscopic  plates.  So,  also,  he  has  not 
included  test-types,  though  he  has  appended,  for 
explanatory  purposes,  the  fan  which  is  often  used 
in  astigmatism.  Admirable  samples  of  the  colored 
wools,  used  in  Holmgren's  tests,  are  sewn  into  the 
cover,  and,  by  aid  of  these,  it  will  be  perfectly  within 


the  power  of  any  one,  wherever  residing,  to  make  a 
proper  collection  of  colored  wools  and  tests  for  the 
qualitative  estimation  of  congenital  color-defects. 
We  have  criticised  the  book  at  length,  and  drawn  at- 
tention freely  to  points  on  which  the  author's  opin- 
ion is  at  variance  with  the  commonly  received  teach- 
ing. This  we  have  done  because  there  is  much 
individuality  in  the  work,  which  bears  every  mark 
of  having  been  well  thought  out  and  independently 
written.  In  these  respects  it  presents  a  marked  su- 
periority over  the  ordinary  run  of  medical  hand- 
books ;  and  we  have  no  hesitation  in  recommending 
it  to  students  and  young  practitioners  as  one  of  the 
very  best,  if  not  actually  the  best,  work  to  procure 
on  the  subject  of  ophthalmology." — British  Medi- 
cal yournal. 


DISEASES  OF  THE  HEART  AND  THORACIC  AOR- 
TA. By  Byrom  Bramwell,  M.  D.,  F.  R.  C.  P.  E.,  Lecturer  on  the  Prin- 
ciples and  Practice  of  Medicine  and  on  Medical  Diagnosis  in  the  Extra- 
Academical  School  of  Medicine,  Edinburgh  ;  Pathologist  to  the  Royal 
Infirmary,  Edinburgh,  etc. 

Illustrated  with  226  Wood  Engravings  and  68  Lithograph  Plates,  showing  gi  Figures — in  all, 
317  Illustrations.     1  vol.,  Svo,  783  pages.     Cloth,  $8.00  ;  sheep,  $9.00. 


"  A  careful  perusal  of  this  work  will  well  repay 
the  student  and  refresh  the  memory  of  the  busy 
practitioner.  It  is  the  outcome  of  sound  knowledge 
and  solid  work,  and  thus  devoid  of  all  '  padding,' 
which  forms  the  bulk  of  many  monographs  on  this 
and  other  subjects.  The  material  is  treated  with 
due  regard  to  its  proportionate  importance,  and  the 
author  has  well  and  wisely  carried  out  his  apparent 
intention  of  rather  furnishing  a  groundwork  of 
knowledge  on  which  the  reader  must  build  for  him- 
self by  personal  observation,  than  of  making  excur- 
sions into  the  region  of  dogma  and  of  fancy  by 
which  his  book  might  have  secured  a  perhaps  more 
rapid  but  certainly  a  more  evanescent  success  than 
that  which  it  will  now  undoubtedly  and  deservedly 
attain." — Medical  Times  and  Gazette. 

"In  this  elegant  and  profusely  illustrated  vol- 
ume Dr.  Bramwell  Has  entered  a  field  which  has 
hitherto  been  so  worthily  occupied  by  British  au- 
thors— Hope,  Hayden,  Walshe,   and   others ;   and 


we  can  not  but  admire  the  industry  and  care  which 
he  has  bestowed  upon  the  work.  As  it  stands,  it 
may  fairly  be  taken  as  representing  the  stand-point 
at  which  we  have  arrived  in  cardiac  physiology  and 
pathology ;  for  the  book  opens  with  an  extended 
account  of  physiological  facts,  and  especially  the 
advances  made  of  late  years  in  the  neuro-muscular 
mechanism  of  the  heart  and  blood-vessels.  Al- 
though in  this  respect  physiological  research  has 
outstripped  clinical  and  pathological  observation, 
Dr.  Bramwell  has,  we  think,  done  wisely  in  so  in- 
troducing his  treatise,  and  has  thereby  greatly  add- 
ed to  its  value.  A  chapter  upon  thoracic  aneurism 
terminates  a  work  which,  from  the  scientific  man- 
ner in  which  the  subject  is  treated,  from  the  care 
and  discrimination  exhibited,  and  the  copious  elab- 
orate illustrations  with  which  it  is  adorned,  is  one 
which  will  advance  the  author's  reputation  as  a 
most  industrious  and  painstaking  clinical  observer." 
— Lancet. 


THE    ESSENTIALS    OF    ANATOMY,    PHYSIOLOGY, 

AND    HYGIENE.     By  Roger  S.   Tracy,  M.  D.,  Sanitary  Inspector  of 
the  New  York  City  Health  Department. 

i2mo.     Cloth,  $1.25. 

This  work  has  been  prepared  in  response  to  the  demand  for  a  thoroughly  scientific  and  yet 
practical  text-book  for  schools  and  academies,  which  shall  afford  an  accurate  knowledge  of  the 
essential  facts  of  Anatomy  and  Physiology,  as  furnishing  a  scientific  basis  for  the  study  of 
Hygiene  and  the  Laws  of  Health.  It  also  treats,  in  a  rational  manner,  of  the  physiological  effects 
of  alcohol  and  other  narcotics,  fulfilling  all  the  requirements  of  recent  legislative  enactments  upon 
this  subject. 


D.   APPLETON  &-   CO:S  MEDICAL    WORKS. 


43 


THE   RELATION   OF  ANIMAL   DISEASES   TO   THE 

PUBLIC  HEALTH,  and  their  Prevention  :  With  a  Brief  Historical 
Sketch  of  the  Development  of  Veterinary  Medicine,  from  the  Earliest  Ages 
to  the  Present  Time  ;  and  a  Critical  Historical  Sketch  of  the  Leading 
Schools  of  the  World,  showing  the  Reasons  which  led  to  their  Foundation, 
and  with  the  Endeavor  to  draw  from  their  Experiences  Teachings  of  Value 
toward  the  Establishment  of  a  General  Veterinary  Police-hygienic  System 
and  Veterinary  Schools  in  this  Country.  By  Frank  S.  Billings,  Veteri- 
nary Surgeon,  Graduate  of  the  Royal  Veterinary  Institute,  Berlin  ;  Mem- 
ber of  the  Royal  Veterinary  Association  of  the  Province  of  Brandenburg, 
Prussia ;  Honorary  Member  of  the  Veterinary  Society  of  Montreal,  Can- 
ada, etc.,  etc. 

I  vol.,  8vo.     Cloth,  $4.00. 


"This  is  the  great  health-book  of  Dr.  Frank  S. 
BilHngs,  and  it  is  not  too  much  to  promise  that  a 
study  and  observance  of  its  teachings,  that  are  the 
results  of  actual  experiments,  will  work  a  revolution 
in  the  sanitary  condition  of  the  United  States.  .  .  . 
It  is  a  work  for  all  stock-breeders  and  for  all  fami- 
lies."— Louisville  Courier- Journal. 

"  This  is  the  title  of  a  work  just  given  to  the 
world,  and  in  its  pages  subjects  of  vital  interest  are 
treated  of  in  a  lucid. and  perspicuous  manner.  .  .  . 
These  well-established  statements  should  arouse  the 
public  feeling  to  provide  that  boards  of  health 
should  be  careful  and  efficient  in  the  exercise  of 
their  duties,  as  also  that,  as  individuals,  every  one 
should  labor  to  take  good  care  of  himself,  his  fam- 
ily, and  his  domestic  animals." — New  York  Times. 

"  This  handsome  volume  does  gjeat  credit  to  its 
author  and  publishers.  It  is  an  excellent  book  in 
most  respects,  an  extraordinary  one  in  many,  and 
an  objectionable  one  in  very  few.      It  at  the  very 


least  should  be  in  the  libraries  of  every  national. 
State,  city,  town,  and  county  Board  of  Health.  It 
certainly  should  be  studied  by  every  teacher  and 
scientific  practitioner  of  veterinary  medicine,  and 
will  be  of  great  service  to  every  great  stock  and  cat- 
tle holder  and  dealer.  ...  It  is  evidently  written 
by  a  man  of  great  ability  and  high  culture,  well 
versed  both  in  the  literature  and  science  as  well  as 
the  practical  bearings  of  his  subject.  Such  a  man 
has  a  great  and  inalienable  right  to  have  opinions 
of  his  own  ;  and  he  has  them,  and  does  not  hesitate 
to  express  them.  .  .  .  We  hope  and  believe  that 
the  volume  will  be  received  by  all,  except  perhaps 
by  those  especially  attacked,  with  the  great  welcome 
that  its  author  and  publishers  must  expect  for  it. 
It  will  take  its  stand  alongside  of  the  popular  trea- 
tises of  Hilliard  and  Robertson,  and  on  all  purely 
scientific  matters  will  lead  them.  Either  of  these 
works,  together  with  Dr.  Billings's,  will  make  al- 
most a  complete  library  on  veterinary  medicine." — 
Journal  0/  Comparative  Medicine  and  Surgery. 


PYURIA;  OR,  PUS  IN  THE  URINE,  AND  ITS  TREAT- 
MENT :  Comprising  the  Diagnosis  and  Treatment  of  Acute  and  Chronic 
Urethritis,  Prostatitis,  Cystitis,  and  Pyelitis,  with  especial  reference  to  their 
Local  Treatment.  By  Dr.  Robert  Ultzmann,  Professor  of  Genito-Uri- 
nary  Diseases  in  the  Vienna  Poliklinik.  Translated,  by  permission,  by  Dr. 
Walter  B.  Platt,  F.  R.  C.  S.  (Eng.),  Baltimore. 

i2mo.     Cloth,  $1.00. 


"  Those  of  the  profession  who  are  familiar  with 
the  works  of  Professor  Ultzmann  will  welcome  this 
translation  as  constituting  a  real  addition  to  our  lit- 
erature on  genito-urmary  diseases.  It  can  not  be 
too  highly  recommended  to  the  attention  of  the  pro- 
fession, not  only  on  account  of  its  scientific  value. 


but  also  for  the  many  practical  suggestions  regard- 
ing treatment  to  be  found  in  the  chapter  on  Thera- 
peutics. The  translator  is  to  be  congratulated  upon 
the  excellent  manner  in  which  his  work  has  been 
accomplished.  The  book  is  neatly  and  tastefully  got 
up  by  the  publishers." — Maryland  Med.  Journal. 


HAND-BOOK   OF   SANITARY  INFORMATION   FOR 

HOUSEHOLDERS.  Containing  Facts  and  Suggestions  about  Ventila- 
tion, Drainage,  Care  of  Contagious  Diseases,  Disinfection,  Food,  and 
Water.  With  Appendices  on  Disinfectants  and  Plumbers'  Materials.  By 
Roger  S.  Tracy,  M.  D.,  Sanitary  Inspector  of  the  New  York  City  Health 

Department. 

i6mo.     Cloth,  50  cents. 


44 


D.   APPLE  TON   &>   CO.'S  MEDICAL    WORKS. 


A  TREATISE  ON  NERVOUS  DISEASES:  Their  Symp- 
toms and  Treatment.  A  Text-book  for  Students  and  Practitioners.  By  S. 
G.  Webber,  M.  D.,  Clinical  Instructor  in  Nervous  Diseases,  Harvard  Med- 
ical School ;  Visiting  Physician  for  Diseases  of  the  Nervous  System  at  the 
Boston  City  Hospital,  etc. 

I  vol.,  8vo,  415  pp.      15  Illustrations.     Cloth,  $3.00. 

"  The  book  before  us  is  especially  adapted  to  the 
needs  of  the  general  practitioner  who,  though  con- 
scious of  his  inability  to  discern  and  trace  the  nerv- 
ous element  in  the  cases,under  his  care,  realizes 
very  fully  that  this  inability  is  not  consonant  with 
the  best  interests  of  his  patient.  Dr.  Webber  has 
not  written  for  the  specialist,  but  for  the  student 
and  general  practitioner,  who  will  find  in  his  book 
what  they  most  need  for  the  diagnosis  and  treat- 
ment of  the  diseases  as  they  present  themselves  in 
general  practice.  His  style  is  very  readable  and 
lucid,  and  is  well  adapted  to  those  who  have  not 
specially   prepared    themselves  to  understand  the 


peculiar  language  of  the  more  advanced  neurologist. 
He  covers  very  completely  the  field  of  nervous  affec- 
tions, and  his  book  will  prove  a  very  valuable  acqui- 
sition to  the  library  of  the  intelligent  physician." — 

Medical  Age. 

' '  The  beauty  and  usefulness  of  the  book  are  much 
enhanced  by  the  fact  that  it  is  not  loaded  down  with 
references  to  other  authors,  but  proceeds  in  an  orig- 
inal manner  to  sum  up  all  that  is  known  to  the 
present  day  upon  the  subjects  treated.  Taking  the 
book  as  a  wliole  it  is  one  of  the  best  we  have  seen 
in  many  a  day." — Texas  Courier-Record. 


THE  CURABILITY  AND  TREATMENT  OF  PUL- 
MONARY PHTHISIS.  By  S.  Jaccoud,  Professor  of  Medical  Pathology 
to  the  Faculty  of  Paris ;  Member  of  the  Academy  of  Medicine ;  Physician 
to  the  Lariboisiere  Hospital,  Paris,  etc.  Translated  and  edited  by  Montagu 
Lubbock,  M.  D.  (London  and  Paris),  M.  R.  C.  P.  (England),  etc. 
8vo,  407  pp.     Cloth,  $4.00. 


"  This  is  the  work  of  that  most  eminent  French- 
man of  the  Ecole  de  Medecine  of  Paris,  and  the 
translation  of  Lubbock  is  strong  and  masterly  inas- 
much as  it  evidences  the  possession  of  a  large 
vocabulary  knowledge  of  both  the  original  and 
English.  No  man  of  the  present  day,  with  the 
single  exception  perhaps  of  Hughes  Bennet,  has 
devoted  as  much  careful  study  to  the  climatic  treat- 
ment of  phthisis  as  Dr.  Jaccoud,  and  his  conclusions 
on  this  point  so  far  as  regards  the  Continent  of 
Europe  must  be  deemed  final." — Cincinnati  Lancet 
and  Clinic. 


"M.  Jaccoud,  the  author  of  the  work,  and  the 
eminent  professor  of  the  Ecole  de  MMecine,  Paris, 
is  generally  recognized  on  the  Continent  as  one  of 
the  best  authorities  on  pulmonary  phthisis,  so  that 
an  English  edition  of  his  work  will  certainly  be 
very  acceptable  to  those  interested  in  the  subject. 
.  .  .  M.  Jaccoud' s  reputation  is  justly  so  great  that 
his  opinions  with  respect  to  the  treatment  will  be 
read  with  general  interest." — Texas  Courier-Record 
of  Medicine. 


THE    USE    OF   THE    MICROSCOPE    IN    CLINICAL 

AND  PATHOLOGICAL  EXAMINATIONS.    By  Dr.  Carl  Friedlaen- 
DER,  Privat-Docent  in  Pathological  Anatomy  in  Berlin.     Translated  from 
the  enlarged  and  improved  second  edition,  by  Henry  C.  Coe,  M.  D.,  etc. 
With  a  Chromo-Lithograph.     r2mo,  195  pp.,  with  copious  Index.     Cloth,  $1.00. 


"  We  are  very  much  pleased  to  see  Dr.  Fried- 
laender's  little  book  make  its  appearance  in  English 
dress.  As  we  have  a  practical  acquaintance  of  the 
German  edition  since  its  appearance,  we  can  speak 
of  it  in  terms  of  unqualified  praise.  .  .  .  Every  one 
doing  pathological  work  sliould  have  this  little  book 
in  his  possession.  .  .  .  The  translator  has  done  his 
work  well,  and  has  certainly  conferred  a  great  favor 
on  all  microscopists  by  placing  within  the  reach  of 
every  one  the  work  of  so  accomplished  a  teacher  as 
Dr.  Carl  F'riedlaender." — Canada  Medical  and  Sur- 
gical Journal. 


"  Much  good  has  been  done  in  placing  this  little 
work  in  the  hands  of  the  profession.  The  technique 
of  preparing,  cutting,  and  staining  specimens  is 
given  at  some  length  ;  also  rules  for  the  examination 
of  the  various  bodily  fluids  in  both  health  and 
disease.  The  use  of  the  microscope  with  high  pow- 
ers, immersion  lenses,  and  other  accessories,  is  ex- 
plained very  clearly.  It  is  a  very  readable  volume, 
even  for  those  not  engaged  in  actual  laboratory 
work.  A  chromo-lithograph  shows  the  various 
forms  of  disease-germs  which  have  been  definitely 
isolated." — Medical  Reco7-d. 


MEDICAL   ETHICS    AND    ETIQUETTE.     Commentaries 

on  the  National  Code  of  Ethics.     By  Austin  Flint,  M.  D. 
i2mo,  loi  pp.     60  cents. 


D.   APPLE  TON  &-   CO.'S  MEDICAL    WORKS. 


45 


A  MANUAL  OF  DERMATOLOGY.     By  A.  R.  Robinson, 

M.  B.,  L.  R.  C.  P.  and  S.  (Edinburgh),  Professor  of  Dermatology  at  the 
New  York  Polyclinic  ;  Professor  of  Histology  and  Pathological  Anatomy  at 
the  Woman's  Medical  College  of  the  New  York  Infirmary.  Revised  and 
corrected. 

8vo,  647  pp.     Cloth,  $5.00. 


"It  includes  so  much  good,  original  work,  and 
so  well  illustrates  the  best  practical  teachings  of  the 
subject  by  our  most  advanced  men,  that  I  regard  it 
as  commanding  at  once  a  place  in  the  very  front 
rank  of  all  authorities.  .  .  .  " — James  Nevins 
HVDE,  M.  D. 

"  Dr.  Robinson's  experience  has  amply  qualified 
him  for  the  task  which  he  assumed,  and  he  has  given 
us  a  book  which  commends  itself  to  the  considera- 
tion of  the  general  practitioner." — Medical  Age. 


"  In  general  appearance  it  is  similar  to  Duhring's 
excellent  book,  more  valuable,  however,  in  that  it 
contains  much  later  views,  and  also  on  account  of 
the  excellence  of  the  anatomical  description  accom- 
panying the  microscopical  appearances  of  the  diseases 
spoken  of." — St.  Louis  Med.  and  Sn?'g.  yournal. 

' '  Altogether  it  is  an  excellent  work,  helpful  to 
every  one  who  consults  its  pages  for  aid  in  the  study 
of  skin-diseases.  No  physican  who  studies  it  will 
regret  the  placing  of  it  in  his  library." — Detroit 
Lancet. 


AN  ATLAS   OF  CLINICAL  MICROSCOPY.     By  Alex- 
ander Peyer,  M.  D.    Translated  and  edited  by  Alfred  C.  Girard,  M.  D., 
Assistant  Surgeon  United  States  Army.      First  American,  from  the  manu- 
script of  the  second  German  edition,  with  Additions. 
90  Plates,  with  105  Illustrations,  Chromo-Lithographs.     Square  8vo.     Cloth,  $6.00. 


"AU  who  are  interested  in  clinical  microscopy 
will  be  pleased  with  the  design  and  execution  of  this 
work,  and  will  feel  under  obligation  to  the  author, 
translator,  and  publishers  for  placing  so  valuable  a 
work  in  their  hands.  The  plates  in  which  are  figured 
the  various  urinary  inorganic  deposits  are  especially 
fine,  and  the  various  forms  of  tube-casts,  hyaline, 
waxy,  epithelial,  and  mucous,  are  depicted  with  great 
fidelity  and  accuracy." — Pliiladelphia  Med.  Times. 

' '  To  those  students  and  practitioners  of  medicine 
who  are  interested  in  microscopical  work  and  who 


are  familiar  with  the  use  of  this  valuable  aid  to  hu- 
man vision  in  the  study  of  nature,  the  present  work 
will  prove  of  incalculable  value,  since  it  represents 
the  original  work  of  an  accomplished  microscopist 
and  artist.  Accompanying  the  plates  is  a  text  of 
explanatory  notes  showing  the  various  methods  of 
working  with  the  microscope  and  the  significance  of 
what  is  obsarved.  The  plates  have  been  most 
handsomely  printed.  We  have  seen  nothing  in  this 
special  line  of  study  that  will  compare  in  point  of 
accuracy  of  detail  and  artistic  effect  with  the  work 
under  consideration." — Maryland  Med.  Joia-nal. 


ELEMENTS  OF  MODERN  MEDICINE,  including  Princi- 
ples of  Pathology  and  Therapeutics,  with  many  Useful  Memoranda  and 
Valuable  Tables  of  Reference.  Accompanied  by  Pocket  Fever  Charts. 
Designed  for  the  Use  of  Students  and  Practitioners  of  Medicine.  By  R. 
French  Stone,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and 
Clinical  Medicine  in  the  Central  College  of  Physicians  and  Surgeons, 
Indianapolis  ;  Physician  to  the  Indiana  Institute  for  the  Blind ;  Consulting 
Physician  to  the  Indianapolis  City  Hospital,  etc.,  etc. 

In  wallet-book  form,  wjth  pockets  on  each  cover  for  Memoranda,  Temperature  Charts,  etc.,  $2.50. 


"  This  is  an  abridged  work  in  pocket-book  form, 
presenting  the  more  advanced  views  of  leading 
authorities,  with  reference  to  general  patholog>'  and 
therapeutics.  Under  general  pathology  are  included 
articles  on  the  origin,  nature,  and  duration  of  dis- 
ease, chief  symptoms,  diagnosis,  prognosis,  and 
treatment.  In  the  second  part  will  be  found  what  is 
regarded  by  the  author  as  an  improved  classiScation 
of  drugs,  followed  b}'  articles  on  their  physiological 
action,  indications,  and  methods  of  use.  The  work 
contains  a  fund  of  useful  information  culled  from 
the  best  authorities  in  the  Old  and  New  World." — 
Canada  Lancet. 


"  This  is  a  neatly  printed  pocket  manual  of  medi- 
cal practice.  It  is  a  well-condensed  compilation  of 
the  kind,  containing  a  short  sketch  of  nearlj'  every- 
thing that  is  met  with  in  practice.  The  fever  charts 
are  well  arranged,  and  there  is  a  convenient  thera- 
peutic table  which  will  be  found  valuable.  It  will 
probably  be  more  suitable  for  young  practitioners, 
on  account  of  its  containing  many  practical  points 
that  are  not  to  be  found  elsewhere  in  such  a  con- 
densed manner.  It  will  be  found  a  valuable  aid  to 
those  just  commencing  practice." — Medical  Herald. 


46 


D.   APPLETON   &-   CO.'S  MEDICAL    WORKS. 


A  TEXT-BOOK  OF  OPHTHALMOSCOPY.  By  Edward 
G.  LoRiNG,  M.  D.  Part  I. — The  Normal  Eye,  Determination  of  Refrac- 
tion, and  Diseases  of  the  Media. 


Specimen  of  Illustration. 


8vo.  267  pp.,  with  131 
Illustrations,  and  Four 
Chromo -Lithograph  Plates, 
containing  14  Figures. 
Cloth,  $5.00. 


"The  '  Text-book  of  Oph- 
thalmoscopy,' by  Edward  G. 
Loring,  M.  D.,  is  a  splendid 
work.  ...  I  am  well  pleased 
with  it,  and  am  satisfied  that 
it  will  be  of  service  both  to 
the  teacher  and  pupil.  .  .  . 
In  this  book  Dr.  Loring  has 
given  us  a  substantial  exposi- 
tion of  Nature's  deeds  and 
misdeeds  as  they  are  found 
written  in  the  eye,  and  the 
key  by  means  of  which  they 
can  be  comprehended." — W. 
R.  Amick,  a.  M.,  M.  D.,  Pro- 
fessor of  Ophthalmology  and 
Otology^  Cincinnati  College 
of  Medicine  and  Surgery. 


THE  DISEASES  OF  SEDENTARY  AND  ADVANCED 

LIFE.     A  Work  for  Medical  and  Lay  Readers.     By  J.  Milner  Foth- 

ERGiLL,  M.  D.,  M.  R.  C.  P.,  Physician  to  the  City  of  London  Hospital  for 

Diseases  of  the  Chest  (Victoria  Park) ;  late  Assistant  Physician  to  the  West 

London  Hospital;    Hon.  M.  D.,  Rush  Medical  College,  Chicago;    Foreign 

Associate  Fellow  of  the  Royal  College  of  Physicians  of  Philadelphia. 

Small  8vo,  296  pp.     Cloth,  $2.00. 

"This  work  is  written  to  fill  a  gap  in  medical  forgotten.  .  .  .  The  writer  ventures  to  think  that  in 

literature.     The  diseases  of  sedentary  and  advanced  this  work  an  aspect  of  disease  is  presented  which  is 

life  lie  a  little  outside  and  beyond  the  ordinary  text-  not  always  kept  sufficiently  in  view  ;  and  which  will 

books  of  practice  of  physic.    As  such  a  work  is  cer-  make  the  work  acceptable  even  to  some  well-read 

tain  to  be  read  by  lay-readers,  the  fact  has  not  been  members  of  the  profession." — From  the  Preface. 

THE  DIAGNOSIS  AND  TREATMENT  OF  DISEASES 

OF  THE  EAR.  By  Oren  D.  Pomeroy,  M.  D.,  Surgeon  to  the  Manhat- 
tan Eye  and  Ear  Hospital,  etc.  With  One  Hundred  Illustrations.  New 
edition,  revised  and  enlarged. 

Cloth,  $3.00. 


8vo. 

"The  several  forms  of  aural  disease  are  dealt 
with  in  a  manner  exceedingly  satisfactory.  The 
work  is  quite  exhaustive  in  its  scope,  and  will  repre- 
sent an  authority  on  this  subject  which  we  believe 
will  be  duly  appreciated  by  the  profession." — Medi- 
cal Record. 

''The  author  uses  good  language,  telling  in  a 
clear  and  interesting  manner  what  he  has  to  say. 
The  book  is  a  valuable  one  for  both  students  and 
practitioners." — Lancet  and  Clinic. 


"The  author's  opportunity  to  know  of  what  he 
writes  has  been  abundant,  and  the  work  itself  shows 
that  hs  has  made  good  use  of  his  information.  We 
have  not  the  slightest  reason  for  not  commending  it 
not  only  to  the  otologist  but  also  to  the  general 
student. " —  Therapeutic  Gazette. 

"  Well  arranged  and  well  written,  and  not  too 
scientific.'' — Boston  Medical  and  Surgical  Jour- 
nal. 


D.  APPLE  TON  &-  CO.'S  MEDICAL   WORKS. 


47 


LOCAL    ANAESTHESIA    IN    GENERAL    MEDICINE 

AND  SURGERY.  Being  the  Practical  Application  of  the  Author's  Re- 
cent Discoveries  in  Local  Anaesthesia.  By  J.  Leonard  Corning,  M.  D., 
author  of  "  Brain  Exhaustion,"  "  Carotid  Compression,"  "Brain  Rest,"  etc. ; 
Fellow  ot  the  New  York  Academy  of  Medicine,  Member  of  the  Medical 
Society  of  the  County  of  New  York,  of  the  New  York  Neurological 
Society,  etc. 

Small  8vo,  103  pp.     With  14  Illustrations.     Cloth,  $1.25. 

"  The  work  has  in  it  much  that  is  instructive  and 
attractive,  and  is  quite  an  addition  to  a  field  of  lit- 
erature which  may  be  considered  novel.  .  .  ." — 
College  and  Clinical  Record. 


"  The  book  should  find  its  way  everywhere  on  its 
merits,  and  will  be  welcomed  by  a  host  of  interested 
readers." — Medical  Press  0/  Westerti  New  York. 

"This  is  a  valuable  little  work  on  cocaine,  giving 
the  author's  method  of  increasing  and  prolonging 
the  cocaine  anesthesia.  .  .  .  Some  very  formidable 
operations,  even  amputation  of  the  thigh,  have  been 
performed  by  this  method  and  with  but  very  little 
pain.  It  is  a  valuable  contribution  to  surgical  prac- 
tice."— Peoria  Medical  Monthly. 

"The  book  merits  careful  consideration,  as  being 
an  interesting  and  practical  original  contribution  to 
surgery." — Medical  Bulletin. 

' '  The  work  is  worthy  the  careful  study  of  every 
practical  surgeon  and  physician.     It  is  clearly  writ- 


ten, with  little  useless  padding.  The  author  stops 
when  he  has  said  what  he  wishes." — American 
Lancet. 

"To  Dr.  Corning  belongs  the  honor  of  discov- 
ering that  cocaine  anaesthesia  may  be  almost  indefi- 
nitely prolonged  by  checking  the  circulation  in  the 
part  anaesthetized  by  means  of  an  Esmarch's  band- 
age, and  any  one  desiring  full  details  should  send  to 
the  Appletons  for  this  neat  little  work." — Kansas 
City  Medical  Itidex. 

"It  is  of  interest  to  note  the  author's -statement 
that  the  '  discovery  in  question  was  in  no  respect  the 
result  of  a  chance,  but  was,  on  the  contrary,  the  di- 
rect outgrowth  of  a  chain  of  deductive  reasoning.' 
The  importance  of  this  discovery  needs  no  insisting 
on ;  and  no  surgeon  can  afford  to  be  in  ignorance 
of  its  details,  or  can  fail  to  be  scientifically  the  richer 
for  the  possession  of  the  present  work." — New  Eng- 
land Medical  Gazette. 


A  TEXT-BOOK  OF  NURSING.     For  the  Use  of  Training- 

Schools,  Families,  and  Private  Students.     Compiled  by  Clara  S.  WeekS) 

Graduate  of  the  New  York  Hospital  Training- School ;   Superintendent  of 

Training-School  for  Nurses,  Paterson,  New  Jersey. 

I2mo,  396  pp.,  with  13  Illustrations,  Questions  for  Review  and  Examination,  and  Vocabulary  of 

Medical  Terms.     $1.75. 


' '  This  book,  in  twenty-three  chapters,  communi- 
cates a  large  quantity  of  useful  information  in  a 
form  intelligible  to  the  public.  It  is  well  written, 
remarkablv  correct,  sufficiently  illustrated,  and  hand- 
somelv  printed.  The  amount  of  technical  skill  and 
knowledge  required  of  nurses  at  the  present  day 
makes  the  use  of  some  text-book  indispensable. 
To  those  who  need  such  a  work  we  can  speak  ap- 


provingly  of  its  design,  scope,  and   execution." — 
Philadelphia  Medical  Tiines. 

"  This  is  an  admirably  written  book,  and  is  full 
of  those  important  practical  details  necessary  for 
the  medical  and  surgical  nurse.  In  fact,  it  could  be 
read  with  profit  by  every  medical  student  and  young 
practitioner." — Medical  Record. 


MEDICINE  OF  THE  FUTURE.     An  Address  prepared  for 

the  Annual  Meeting  of  the  British  Medical  Association  in  1886.     By  Aus- 
tin Flint  (Senior),  M.  D.,  LL.  D. 

With  Steel  Engraving  of  the  author.     l2mo,  37  pages.     Cloth,  $1.00. 

"  The  above,  the  last  of  the  thoughts  of  Austin 
Flint,  should  be  in  the  hands  of  every  admirer  of 
the  great  and  good  physician,  and  who  that  knows 
anything  of  American  medicine  did  not  admire 
him  ?  iFlint  never  wrote  anything  that  was  not 
good,  and  the  nice  little  hooK—soiivenir—h^'i.oxfi  us 
bears  that  characteristic.  The  manuscript  was  found 
among  his  papers  after  his  death,  and  was  printed 
just  as  it  was  written.  It  contains  a  good  likeness 
of  the  author— an  elegant  steel  engraving— and 
nothing  has  been  left  undone  by  the  well-known 
publishers  to  make  it  sXtxasXiv^:'— Mississippi  Val- 
ley Medical  Monthly. 


"  The  late  Dr.  Austin  Flint  was  appointed  to 
read  the  address  on  Medicine  before  the  British 
Medical  Association  at  its  meeting  in  1SS6.  The 
manuscript  was  found  among  his  papers,  and  the 
address  is  printed  precisely  as  it  was  written.  The 
proof  was  reverently  read  by  his  son,  who  dedicates 
this,  his  father's  last  literary  work,  to  the  profession 
he  so  loved  and  admired.  The  book  contains  an 
excellent  portrait  of  the  late  Dr.  Flint.  It  is  a  most 
fitting  memor'al  volume.  The  address  itself  is  a 
most  scholarly  work,  and  should  be  added  to  the 
library  of  every  -pxzzXSXion^r."''— Buffalo  Medical  and 
Surgical  yournal. 


48 


D.  APPLE  TON  &-  CO.'S  MEDICAL   WORKS. 


A 


TEXT-BOOK  OF  MEDICINE.  For  Students  and  Prac- 
titioners. By  Adolph  Strumpell,  formerly  Professor  and  Director  of  the 
Medical  Polyclinic  at  the  University  of  Leipsic.  Translated,  by  permission, 
from  the  second  and  third  German  editions  by  Herman  F.  Vickery,  A.  B., 
M.  D.,  Assistant  in  Clinical  Medicine,  Harvard  Medical  School,  etc.,  and 
Philip  Coombs  Knapp,  Physician  to  Out-patients  with  Diseases  of  the 
Nervous  System,  Boston  City  Hospital,  etc.  With  Editorial  Notes  by 
Frederick  C.  Shattuck,  A.  M.,  M.  D.,  Instructor  in  the  Theory  and  Prac- 
tice of  Physic,  Harvard  Medical  School,  etc. 

With  III  Illustrations.     8vo,  981  pages.     Cloth,  $6.00;  sheep,  $7.00. 

"  The  above  work,  which  is  new  to  most  of  our 
readers,  has  achieved  great  success  in  Germany,  hav- 
ing reached  the  third  edition  in  a  verj'  short  time. 
It  has  been  introduced  as  the  text-book  on  medicine 
in  the  Har\'ard  Medical  School.  The  work  is  espe- 
cially commendable  in  its  treatment  of  nervous  dis- 
eases, which  are  dealt  with  fully,  concisely,  and 
clearly.  The  patholog)'  of  disease,  as  might  be  ex- 
pected from  so  eminent  a  teacher,  has  received  due 
and  careful  attention,  and  this  is  another  strong 
feature  of  the  work.  The  author  gives  in  this  work 
the  results  of  the  experience  and  observation  of  more 
than  six  years'  active  work  in  the  medical  clinic  in 
Leipsic.  We  heartily  commend  the  work  to  the  at- 
tention of  our  readers." — Canada  La?icet. 

"  In  spite  of  the  fact  that  within  the  last  year  or 
two  so  many  excellent  works  on  general  medicine 
have  appeared,  we  think  there  will  be  found  a  place 
for  the  volume  before  us.  The  best  part  of  the  book 
is  the  section  devoted  to  nervous  diseases.  The  va- 
rious affections  of  the  ner\'Ous  system  are  discussed 
in  a  very  concise  way,  together  with  the  most  recent 
discoveries  in  neuro-pathology.  The  translators 
have  done  their  work  well,  and  the  editor  has  made 
a  number  of  important  additions.  Altogether  the 
book  is  a  very  valuable  contribution  and  compilation, 
and  will  be  useful  both  to  teacher  and  practitioner. " 
— Maryland  Medical  Journal. 

'•  The  work  before  us  is  one  that  is  peculiarly  at- 
tractive to  the  student  of  medicine,  not  only  on  ac- 
count of  the  well  delineated  German  plans  of  treat- 
ment, but  especially  for  the  clear  and  accurate  pa- 
Dr.  Shattuck  states  that  he  is  acquainted  with  no 
work°wli!ch  treats  of  the  diseases  of  the  nervous  system,  in  which  our  knowledge  has  advanced  so  rapidly 
of  late  years,  so  fully,  concisely,  and  clearly.  The  style  is  clear  for  a  German  work,  which  as  a  rule  do 
not  make  models  in  this  particular.  The  translators  have  overcome  the  difficulties  of  the  original  so  suc- 
cessfully that  they  have  made  it  a  decidedly  agreeable  text-book.  The  book  is  extremely  popular  in  Ger- 
many, having  reached  the  third  edition  in  a  comparativelv  short  time,  and  we  do  not  doubt  but  that  its 
popularity  in  Amsrica  will  soon  be  assured."— J/ww^^/^  Valley  Medical  Monthly. 

its  covers  will   be  found  a  very  complete  and  sys- 


Fig.  78. — Spasm  of  the  right  Splenius  Capitis. 
(From   Duchen.ne.) 

thology  given  by  the  author  in  almost  all  diseases. 


"  I  like  it  so  well  that  I  have  commended  it  to 
my  class  and  have  called  special  attention  to  its 
three  hundred  pages  devoted  to  the  nervous  system, 
bringing  to  date  all  the  knowledge  which  the  last  ten 
years,  more  than  many  centuries  past,  have  brought 
to  the   use  of    the  profession." — H.   D.    Didama, 


tematic  description  of  aU  the  diseases  which  are 
classed  under  the  head  of  internal  medicine.  Un- 
like most  of  the  larger  works  on  practice,  we  do  not 
find  the  preliminary  discourse  on  general  pathologi- 
cal subjects,  an  omission  which  is  very  much  to  be 


M.  D.,  Professor  0/  the  Principles  and  Practice  0/    commended,  because  there  are  at  ths  present  day  so 


Medicine  and  Clinical  Medicine,  College  0/  Medi- 
cine, Syracuse  University. 

"  I  consider  it  the  best  text-book  of  medicine 
with  which  I  am  acquainted.  The  part  on  nervous 
diseases  is  so  excellent  that  I  shall  recommend  the 
whole  book  to  my  class  as  a  text-book  on  diseases  of 
the  nervous  system." — Henry  Hu.\,  M.  D.,  LL.  D., 
Dean  0/  the  Faculty  and  fimeritus  Professor  of  the 
Institutes  of  Medicine,  Albany  Medical  College. 

"Of  the  German  text-books  of  practice  that 
have  been  translated  into  Knglish,  Professor  Strum- 
pell's  will  probably  take  the  highest  rank.     Between 


many  special  treatises  upon  pathological  subjects 
that  there  is  no  longer  a  necessity  for  such  a  section 
in  a  work  of  this  kind.  While  it  is  impossible  to 
refer  to  all  these  particularly,  we  may  call  attention 
to  the  chapter  on  Typhoid  Fever  as  being  especially 
valuable,  not  only  on  account  of  the  advanced  views 
in  regard  to  the  pathology  of  that  disease,  but  also 
becau.se  of  the  careful  description  of  its  clinical  his- 
tory and  of  its  treatment.  Taken  altogether,  it  is 
one  of  the  most  valuable  works  on  practice  that  we 
have,  and  one  which  every  studious  practitioner 
should  have  upon  his  shelves." — New  York  Medical 
Journal. 


D.  APPLETON  &-  CO:S  MEDICAL   WORKS. 


49 


Fig.  390. — Making  Plantar  Flap. 


A  MANUAL  OF  OPERATIVE  SURGERY.  By  Joseph 
D.  Bryant,  M.  D.,  Professor  of  Anatomy  and  Clinical  Surgery,  and  Asso- 
ciate Professor  of  Orthopoedic  Surgery  in  Bellevue  Hospital  Medical  Col- 
lege ;  Visiting  Surgeon  to  Bellevue  Hospital,  and  Consulting  Surgeon  to  the 
New  York  Lunatic  Asylum  and  the  Out-Door  Department  of  Bellevue 
Hospital. 

New   edition,  revised  and   enlarged.     With    793    Illustrations.     8vo,  530  pages.      Cloth, 

$5.00;  sheep,  $6.00. 

"The  apolog;)'  given  by  the  author,  if  any  apology  be 
needed  for  the  appearance  of  so  excellent  a  work,  is  the  fre- 
quent request  on  the  part  of  those  whom  it  has  been  his  pleas- 
ure to  instruct  in  operative  surgery  during  ihe  past  few  years, 
to  make  a  book  based  somewhat  on  the  plan  he  has  employed 
in  teaching  this  subject.  We  have  perused  this  work  with 
great  pleasure  and  profit,  and  can  bear  testimony  to  the  care 
and  attention  which  the  author  has  bestowed  to  make  the  book, 
a  benefit  to  his  co-workers  in  the  same  field.  The  cuts  are 
numerous  and  well  executed,  and  the  text  clear  and  well 
printed.  The  various  operative  procedures  are  clearly  and 
concisely  described,  and  the  results  of  the  various  operations 
briefly  stated.  The  chapter  on  the  treatment  of  operation 
wounds  is  worthy  of  special  mention.  The  work  is  fully 
abreast  of  the  most  recent  advances  in  operative  surgerj',  and 
we  have  much  pleasure  in  recommending  it  to  our  readers." — 
Canada  Lancet. 

"  The  author  of  this  work  seems  to  know  how  in  the  brief- 
est space  to  give  the  student  of  surgery  the  aid  necessary  '  to 
acquire  established  facts,'  and  this  is  an  important  point  in  a 
book  of  this  kind.  The  text  is  most  fully  illustrated,  and 
brings  the  subject  to  date,  and  it  will  be  found  useful  in  the 
sphere  to  which  it  belongs  " — A'eio  y'ork  Medical  Times. 

"  The  work  of  Professor  Brj'ant,  while  it  does  not  pretend  to  be  a  rival  of  the  larger  works  or  systems 
of  surgery,  is  of  its  kind  a  most  excellent  book.  Theories  and  doubtful  methods  of  operating  find  no 
place  in  the  volume.  It  is  rather  to  known  facts  and  established  procedures  that  the  author  has  limited 
his  labor,  and  the  judgment  which  he  evinces  in  selecting  from  the  various  methods  of  operating  in  sur- 
gical cases  is  generally  of  a  most  reliable  nature  ;  indeed,  it  is  this  selecting  from  many  proposed  proced- 
ures, which  are  usually  met  with  in  the  larger  surgical  works,  that  much  of  the  value  of  Professor  Bry- 
ant's book  depends,  and  in  this  respect  the  book  becomes  a  very  able  aid  to  the  inexperienced  surgeon. 

The  scope  of  the  work 
includes  most  of  the 
surgical  diseases,  and 
the  operative  meth- 
ods for  their  relief  or 
cure.  The  operations 
peculiar  to  the  female 
sex,  and  the  surgery  of 
the  eye  and  ear,  are 
not  considered  in  the 
book.  ...  In  conclud- 
ing our  notice  of  Pro- 
fessor Bryant's  book,  it 
remains  for  us  to  con- 
gratulate him  upon  the 
successful  result  of  his 
labor.  He  has  written 
a  very  able  and  reliable 
surgical  work,  one  that 
may  be  consulted  both 
by  surgeon  and  stu- 
dent, and  one  that  con- 
tains all  the  more  im- 
portant advances  of 
modem  surgery.  The 
publishers'  part  of  the 
work  has  been  well 
done,  and  the  numer- 
ous illustrations  add 
much  to  the  value  of 
the  volume." — Thera- 
peutic Gazette. 
459. — Compressing  Femoral  Vessels. 


D.  APPLE  TON  (S-  CO:S  MEDICAL   WORKS. 

PRACTICAL      SUGGESTIONS     RESPECTING      THE 

VARIETIES  OF  ELECTRIC  CURRENTS  AND  THE  USES  OF 
ELECTRICITY  IN  MEDICINE,  with  Hints  relating  to  the  Selection 
and  Care  of  Electrical  Apparatus.  By  Ambrose  L.  Ranney,  M.  D.,  Pro- 
fessor of  Nervous  Diseases  in  the  Medical  Department  of  the  University  of 
Vermont ;  Professor  of  the  Anatomy  and  Physiology  of  the  Nervous  System 
in  the  New  York  Post-Graduate  Medical  School  and  Hospital,  etc. 

l6mo,  147  pp.,  with  44  Illustrations  and  14  Plates,  as  an  aid  in  treating  morbid  states  of  the  motor 

or  sensory  apparatus.     $1.00. 

"  It  is  clearly  written,  quite  practical  in  tone,  and  "  It  presents  in  a  condensed  form  the  latest  views 

offers  an  excellent  epitome  of  the  subject."— i/^'f^z-  on  this  important  subject.     Numerous  illustrations 

cal  and  Siir°-ical  Reporter.  increase  the  clearness  with  which  the  author  presents 

"^  .  his  subject.     In  this  form  it  is  more  conveniently 

"This  is  a  useful  httle  work,  presentmg  m  a  reached;  .  .  .  it  is  also  more  conveniently  arranged 

brief  way  the  subject  of  electro-technique  and  elec-  than  it  is  likely  to  be  in  a  large  work  on  the  diag- 

tro-therapeutics."— yl/<?rfzca/j?^i:orrf.  nosis  and  treatment  of  nervous  diseases."— ^/«^/-z'- 

"  It  will  be  found  a  valuable  guide  to  those  wish-  <^<^^  Lancet. 
ing  to  make  use  of  this  powerful  remedial  agent  in  ,,  ^^^  author's  views  are  clear-cut,  sharply  de- 

the  treatment  of  diseases,  —lexas  Courier-Record  ^^^^^  ^^^  presented   in  a  concise  manner,  which 

of  Medicine.  gives' the  reader  a  crystal-like  conception  of  what  he 

"We  recommend  this  little  volume  to  aU  who  3.Vi.tv£i.^\s\.o  zo^svycy.'"— Medical  Herald. 
are  desirous  of  studying  the  simpUfied  elements     It  . ,  ^  .    ^^^  outgrowth  of  an  ex- 

^s  well  Illustrated  and  not  too  voluminous. "-iV^r/>J  -  ■  ^^  ^^^^^^  ^^if^^r^A  on  the  ap- 

Carolina  Medical  Journal.  pHcation  of  electricity  to  disease.     It  is  full  of  prac- 

' '  For  the  practitioner  who  wants  brief  directions  tical  hints  and  many  valuable  cuts,  illustrating  the 

where  to  put  the  positive  pole  and  where  the  nega-  author's  methods." — Denver  Medical  Times. 
tive,  this  is  the  book." — Medical  Press  of  Westej-n 

New  York.  "The  title  of  this  work  sufficiently  indicates  its 

sphere,  and  all  we  need  say  of  it  is  that  it  is  emi- 

"  The  author  is  well  known  as  an  accomplished  nently  practical  and  worthy  of  a  place  as  a  text-book 

writer  and  teacher  on  nervous  diseases,  and  his  con-  in  this  important  and  rapidly  developing  department 

sciousness  that  much  depends,  in  neurology,  upon  a  of  medical  practice. "—iVew  York  Medical  Times. 
knowledge  of  electricity  and  electrical  appliances, 

induced  him  to  prepare  this  very  useful  and  timely  ' '  The  hints  contained  in  it  embrace  the  later 

work,  for  the  benefit  of  those  desiring  to  use  this  ideas  upon  the  best  electrical  apparatus,  and  the  mode 

agent  scientificcdly  and  successfully  in  their  general  of  its  application  in  different  diseased  conditions." — 

practice." — College  and  Clinical  Record.  Hahnemannian. 

GYNECOLOGICAL    TRANSACTIONS,  VOLS.    I    TO 

VII,  will  be  supplied  at  $5.00  a  volume. 

GYNECOLOGICAL  TRANSACTIONS,  VOL.  VIII.    Be- 
ing the  Proceedings  of  the  Eighth  Annual  Meeting  of  the  American  Gynae- 
cological Society,  held  in  Philadelphia,  September  18,  19,  and  20,  1883. 
8vo.    276  pp.    Cloth,  $5.00. 

GYNECOLOGICAL   TRANSACTIONS,  VOL.  IX.     Be- 
ing the  Proceedings  of  the  Ninth  Annual  Meeting  of  the  American  Gynaeco- 
logical Society,  held  in  Chicago,  September  30,  and  October  i  and  2,  1884. 
8vo.     408  pp.     Cloth,  $5.00. 

GYNECOLOGICAL  TRANSACTIONS,  VOL.  X.    Being 

the  Proceedings  of  the  Tenth  Annual  Meeting  of  the  American  Gynseco- 
logical  Society,  held  in  Washington,  D.  C,  September  22,  23,  and  24,  1885. 
8vo.    357  pp.    Cloth,  $5.00. 


D.  APPLE  TON  &-  CO.'S  MEDICAL   WORKS.  5 1 

GYNECOLOGICAL   TRANSACTIONS,  VOL.  XI.     Be- 

ing  the  Proceedings  of  the  Eleventh  Annual  Meeting  of  the  American  Gynae- 
cological Society,  held  in  Baltimore,  September  21,  22,  and  23,  1886. 
8vo.    516  pp.    Cloth,  $5.00. 

GYNECOLOGICAL  TRANSACTIONS,  VOL.  XII.     Be- 

ing  the  Proceedings  of  the  Twelfth  Annual  Meeting  of  the  American  Gynae- 
cological Society,  held  in  New  York  City,  September  13,  14,  and  15,  1887. 
8vo.    512  pp.    Cloth,  $5.00. 

A  TEXT-BOOK  ON  SURGERY:  General,  Operative, 
AND  Mechanical.  By  John  A.  Wyeth,  M.  D.,  Professor  of  General 
and  Genito-Urinary  Surgery  in  the  New  York  Polyclinic  ;  Visiting  Sur- 
geon to  Mount  Sinai  Hospital,  etc. 

Sold  by  Subscription. 


"  The  above  work  we  have  read, 
and  will  judge  it  from  its  title,  viz., 
'A  Text-Book  on"  Surgery,'  or,  in 
other  words,  a  book  to  teach  from  ; 
but  may  we  not  also  look  at  it  from 
the  opposite  side,  and  consider  it  a 
book  to  learn  from  ?  In  answer  to 
the  first  of  these  definitions  we  do 
not  hesitate  to  say  that  Professor 
Wyeth  has  given  us  a  most  excel- 
lent book,  one  in  which  will  be  found 
all  the  advances  of  modern  surgery 
and  all  that  is  good  of  older  sur- 
gery. .  .  .  The  more  important 
question  to  answer  is  in  regard  to 
the  value  of  the  book  as  a  means  of 
obtaining  surgical  knowledge,  and, 
indeed,  it  is  in  this  sense  that  the 
title  of  the  work  must  be  mainly 
considered.  Again  do  we  answer  in 
the  affirmative,  and  believe  of  the 
many  text-books  which  are  in  use 
by  the  medical  colleges,  none  are 
better,  few  are  equal,  and  many  are 
inferior ;  therefore  we  hope  to  see 
this  work  of  Professor  Wyeth's 
recommended  to  those  beginning 
the  study  of  surgery,  since  we  think 
a  good  foundation  to  build  up  a 
knowledge  of  the  science  and  art  of 
surgery  may  be  found  in  it.  Pro- 
fessor Wyeth  is  certainly  to  be  con- 
gratulated for  the  manner  in  which 
his  publishers  have  done  their  part. 
The  illustrations,  the  paper,  the 
typography,  and  in  fact  the  entire 
work  may  be  regarded  as  a  beautiful 
specimen  of  the  art  of  book-mak- 
ing."—  Therapeutic  Gazette. 

" .  .  .  In  order  to  produce  such 
a  work,  and  make  it  satisfactory  to 
those  who  desire  a  guide  thoroughly 
up  to  the  times  in  this  department 
of  medicine,  it  has  evidently  been 
the  author's  aim  to  discard  all  that  has  become  ob- 
solete and  that  is  not  essential,  and  to  present  the 
whole  science  and  art  of  surgery  as  it  is  taught 
and  practiced   at  the  present  day  by  the  ablest 


Specimen  of  Illustration. 


authorities  at  home  and  abroad,  in  a  very  compact 
and  yet  thoroughly  intelligible  form.  That  he  has 
succeeded  in  this  design  the  pages  of  this  beautiful 
volume    seem    clearly    to    indicate.       The    work 


52 


D.  APPLETON  &-  CO.'S  MEDICAL   WORKS. 


Specimen  of  Illustration. 


throughout  is  stamped  with  his  own  individuality, 
and  if  at  times  he  seems  a  little  dogmatic  in  his 
manner,  it  is  because  he  is  speaking  of  matters 
with  which  he  is  thoroughly  conversant,  and  ad- 
vocating methods  the  efficacy  of  which  he  has 
thoroughly  tested  in  a  practical  way.  That  there 
are  honest  differences  of  opinion  on  many  of  the 
points  of  pathology  and  practice  upon  which  he 
treats,  of  course,  goes  without  saying,  but  through- 
out the  work  the  teaching  is  unquestionably  sound 
and  conscientious,  and  if  in  any  given  condition 
only  one  plan  of  treatment  may  be  advised,  it  is 
because  the  author  honestly  believes  it  to  be  the 
best.  Three  years  of  unremitting  toil  have  been 
given  to  the  preparation  of  the  book,  to  say 
nothing  of  the  many  additional  years  of  study, 
teaching,  and  practical  work  of  which  it  is  the 
fruit." — Gaillard's  Medical  Journal. 


"...  The  writing  of  a  surgery  that  shall  be 
new  in  its  matter  is  simply  impo-ssible.  But  the 
author  has  evidently  grasped  and  digested  the  facts 
of  surgery  as  known  to-day,  and,  after  finding 
those  which  best  suited  his  practical  work,  pre- 
sented them  to  his  professional  fellow-workers. 
Others  would  write  a  different  work  from  the  same 
data,  because  no  two  minds  run  in  the  same  direc- 
tion. But  in  this  sense  this  work  is  original.  In 
this  sense  it  will  be  found  interesting  and  instruc- 
tive to  all  students  and  professional  men.  The 
chapter  on  the  ligation  of  arteries  is  worth  the 
price  of  the  entire  work.  The  illustrations  are 
superb,  showing  in  color  the  parts  to  be  met  with 
in  the  reaching  of  arteries  in  every  portion  of  the 
body.  Quite  as  important  and  as  beautifully  illus- 
trated is  the  chapter  on  amputations.  He  who, 
possessing  proper  anatomical  knowledge,  could 
not  by  the  directions  here  given  perform  these 
amputations,  should  be  convinced  that  he  had 
missed  his  calling." — American  Lancet. 


"A  modern  text-book  on  surgery,  provided  it 
professes  to  give  within  a  moderate  compass  a 
satisfactory  account  of  the  general  range  of  sur- 
gery, is  valuable  to  the  general  practitioner  in 
proportion  as  it  makes  details  plain  and  clearly 
presents  their  underlying  principles.  Gauging  it 
on  this  basis,  we  are  convinced  that  Dr.  Wyeth's 
work  will  speedily  take  a  prominent  place  in  the 
esteem  of  the  profession.  ...  In  particular,  we 
would  commend  the  care  that  has  been  bestowed 
on  the  important  matters  of  surgical  dressings, 
bandaging,  and  the  like.  These  details  lie  at  the 
very  foundation  of  success  in  surgical  practice,  and 
too  much  attention  can  scarcely  be  given  to  them 
in  a  text-book.  The  appearance  of  the  book  is  in 
the  highest  degree  creditable  to  the  publishers ; 
the  print  is  clear,  the  paper  is  excellent,  and  the 
illustrations,  which  are  numerous  and  nearly  all 
original,  are  among  the  best  of  their  class  that  we 
have  seen.  They  include  quite  a  number  printed 
in  colors." — New  York  Medical  Journal. 

"As  a  specimen  of  typographical  and  book- 
makers' work  it  is  unexceptionable.  It  is  one  of  the 
handsomest  works  ever  published,  is  profusely  and 
beautifully  illustrated,  having  771  engravings,  of 
which  about  fifty  are  colored,  and  is  printed  in 
large  type  on  heavy  paper.  Nor,  when  we  have 
praised  the  mechanical  work  of  the  book,  have  we 
given  all  of  its  merits.  It  is  undoubtedly  a  useful 
and  convenient  manual  of  surgery.  The  author 
has  kept  himself  thoroughly  posted  in  the  present 
literature  of  his  profession,  and  has  incorporated 
in  his  book  nearly  all  of  the  latest  achievements 
and  notions  in  surgery.  We  believe  the  book  to 
be  the  production  of  a  good  and  conscientious 
surgeon,  and  can  safely  recommend  it  to  the  pro- 
fession."— Medical  Herald. 

' '  The  perusal  of  this  book  by  any  one  interested 
in  surgery  can  not  fail  to  afford  both  pleasure  and 
instruction.  .  .  .  The  illustrations  constitute  a 
special  feature,  for  they  are  used  unsparingly 
throughout  the  entire  work,  and  are  of  a  very 
superior  order  of  merit.  .  .  .  The  book  is  well 
written,  fully  up  with  the  present  status  of  sur- 
gery, is  a  credit  alike  to  author  and  publishers, 
and  would  be  very  cheap  at  double  the  price 
charged  for  it.  It  affords  us  pleasure  to  look  over 
a  book  which  we  can  thus  praise  without  stint, 
knowing  that  we  can  say  nothing  in  excess  of  its 
merits. ' ' — Southern  Clin  ic. 

".  .  .  Its  readers  will  have  nothing  derived 
from  its  study  to  unlearn.  Its  teachings  are  the 
accepted  ones  of  to-day,  while  within  its  nearly 
800  pages  we  have  found  but  very  few  superfluous 
sentences.  ...  In  conclusion,  we  may  say  that  the 
book  is  characterized  throughout  by  good,  practical 
common-sense,  wide  research,  and  excellent  judg- 
ment as  to  what  should  be  left  out  of,  as  well  as 
what  should  enter  into,  a  work  of  this  scope." — 
Canada  Lancet. 

' '  Dr.  Wyeth  has  prepared  a  very  excellent  trea- 
tise on  general,  mechanical,  and  operative  surgery. 
.  .  .  The  work  ...  is  distinctly  what  it  claims  to 
be,  '  A  Text- Book  on  General,  Operative,  and 
Mechanical  Surgery,'  carefully  prepared  and  fully 
up  to  all  the  modern  improvements  in  surgery." — 
New  York  Medical  Times. 

"...  The  eminent  surgeon.  Dr.  Wyeth,  has 
here  presented  a  most  valuable  production.  Though 
styled  a  text-book,  it  is  admirably  adapted  as  a  work 
of  reference  for  the  surgeon  and  practitioner,  giv- 
ing, as  it  does,  the  recent  and  advanced  views  upon 
all  surgical  procedures.  ...  In  short,  the  entire 
book  evinces  the  work  of  a  master-mind  and  a  supe- 
rior operator  in  surgery." — Southern  Med.  Record. 


D.  APPLETON  (Sr-  CO:S  MEDICAL  WORKS. 


53 


OPERATIVE    SURGERY   ON    THE   CADAVER.      By 

Jasper  Jewett  Garmany,  A.  M.,  M.  D.,  F.  R.  C.  S,,  Attending  Surgeon 
to  Out-door  Poor  Dispensary  of  Bellevue  Hospital;  Visiting  Surgeon  to 
Ninety-ninth  Street  Reception  Hospital;  Member  of  the  British  Medical 
Association,  etc. 

Small  8vo.      150  pp.     With  Two  Colored   Diagrams  showing  the  Collateral  Circulation  after 
Ligatures  of  Arteries  of  Arm,  Abdomen,  and   Lower  Extremity.      Cloth,  $2.00. 


"To  the  more  advanced  student  who  has  the 
opportunity  of  operating  on  the  cadaver,  this  work 
will  be  of  great  value,  since  it  reduces  to  a  system 
the  procedure  of  ordinary  surgical  operations.  To 
the  practitioner  it  will  be  valuable  as  a  work  of 
easy  reference  as  to  the  best  methods  of  operation. 
In  fact,  it  should  have  been  named  a  manual  of 
surgical  operations.  The  instructions  given  are 
full,  yet  very  plain  and  concise,  and  we  predict  for 
it  a  wide  circulation." — Peoria  Medical  Monthly. 

".  .  .  In  its  necessarily  limited  scope  it  is 
above  criticism.  .  .  .  Indeed,  there  is  nothing 
superfluous  in  the  book,  and  the  busy  practitioner, 
who  must  do  more  or  less  surgery,  would  find  it  a 
very  useful  manuaJ  for  frequent  reference." — Med- 
ical Press  of  Western  New  York. 

"...  For  the  student  in  the  dead-room,  or  the 
busy  operating  surgeon,  this  book  is  one  of  the 
most  reliable  and  handy  works  we  have  ever  seen." 
— Southern  Clinic. 

"  Post-mortem  surgery  must  always  precede  in- 
telligent and  successful  surgery.  No  more  accept- 
able or  useful  g^ide  to  this  form  of  experimental 


teaching  could  be  desired  than  the  admirable  little 
work  before  us.  Not  a  superfluous  phrase  and 
net  an  obscure  phrase  mars  its  pages.  .  .  ." — New 
England  Medical  Gazette. 

"...  No  space  is  wasted,  either  bywords  or 
by  illustrations,  a  fact  which  we  believe  greatly  en- 
hances its  value  for  the  earnest  student." — Pacific 
Medical  and  Surgical  Journal  and  Western  Lan- 
cet. 

"...  All  the  ordinary  operations  practiced  in 
surgery  are  described  in  a  concise  and  clear  man- 
ner, many  of  the  later  procedures  finding  a  place 
which  are  not  incorporated  in  larger  works  on  sur- 
gery already  before  the  pubUc.  The  book  will 
prove  to  be  a  great  convenience  to  the  practitioner 
in  active  work,  as  well  as  to  the  student  in  the  dis- 
secting-room."—  Weekly  Medical  Review. 

"  This  book  contains  a  simple  and  clear  state- 
ment of  the  way  in  which  a  large  number  of  opera- 
tions are  to  be  performed  on  the  cadaver,  and  can 
be  recommended  to  the  use  of  teachers  and  students 
in  this  important  part  of  a  surgical  education.  ..." 
— Medical  and  Surgical  Reporter. 


FUNCTIONAL  NERVOUS  DISEASES:  Their  Causes 
AND  THEIR  TREATMENT.  Memoir  for  the  Concourse  of  1881-1883, 
Academic  Royale  de  Medecine  de  Belgique.  With  a  Supplement,  on  the 
Anomalies  of  Refraction  and  Accommodation  of  the  Eye,  and  of  the  Oc- 
ular Muscles.  By  George  T.  Stevens,  M.  D.,  Ph.  D.,  Member  of  the 
American  Medical  Association,  of  the  American  Ophthalmological  Society, 
etc. ;  formerly  Professor  of  Ophthalmology  and  Physiology  in  the  Albany 
Medical  College. 

Small  8vo.     217  pp.     With  Six  Photographic  Plates  and  Twelve  Illustrations.     Cloth,  $2.50. 


' '  A  careful  study  of  this  work  will  undoubtedly 
clear  up  many  hitherto  illy  understood  cases  of 
nervous  troubles,  and  will  lead  to  a  more  success- 
ful treatment  of  such.  .  .  .  " — Peoria  Medical 
Monthly. 

"...  We  heartily  commend  his  book  to  all 
thoughtful  students  of  nervous  diseases,  feeling 
sure  that  they  can  not  fail  of  finding  in  it  most 
valuable  suggestions." — Medical  and  Surgical  Re- 
porter. 

".  .  .  It  is  fortunate  for  the  profession  that 
Dr.  Stevens  has  done  his  views  full  justice  in  a 
work  to  which  all  can  have  access,  for  they  cer- 
tainly deserve  careful  attention." — Medical  Press 
of  Western  New  York. 

"...  The  work  is  eminently  suggestive  and 
practical  upon  numerous  points,  and  must  prove 
interesting  and  very  useful  to  the  student  and 
practitioner." — Southern  Medical  Record. 


".  .  .  To  Dr.  Stevens  the  profession  is  un- 
questionably indebted  for  the  discovery  of  a  new 
and  important  class  of  causative  influences  ;  and  no 
physician,  after  a  thoughtful  reading  of  this  ad- 
mirable treatise,  will  fail  to  the  diagnosis  of  an  ex- 
perienced oculist  an  invaluable  aid  to  his  own  in 
any  obstinate  case  of  nervous  disease  under  his 
care.'' — New  England  Medical  Gazette. 

"Dr.  Stevens  has  written  a  suggestive  little 
book,  and  the  mere  fact  that  it  has  excited  criticism 
is  pretty  fair  proof  that  there  is  good  in  it.  For 
our  own  part,  we  confess  that  we  have  derived 
much  pleasure  from  its  perusal.  .  .  .  Finally,  the 
book  is  written  in  a  style  which  is  decidedly  fas- 
cinating. Dr.  Stevens  knows  much  about  English 
prose,  and  he  has  a  well-developed  rhythm  both  in 
ideas  and  words,  and  hence  he  renders  the  assimila- 
tion of  knowledge  easy.  His  monograph  should 
be  read  by  those  who  are  interested  in  the  prob- 
lems of  neuro-pathology." — The  New  York  Medi- 
cal Joui-nal. 


54 


D.   APPLE  TON  <&-   CO:S  MEDICAL    WORKS. 


THE   RULES  OF  ASEPTIC  AND  ANTISEPTIC   SUR- 

GERY.  A  Practical  Treatise  for  the  Use  of  Students  and  the  General 
Practitioner.  By  Arpad  G.  Gerster,  M.  D.,  Professor  of  Surgery  at  the 
New  York  Polyclinic  ;  Visiting  Surgeon  to  the  German  Hospital  and  to 
Mount  Sinai  Hospital,  New  York. 

8vo.     Illustrated  with  Two  Hundred  and  Forty-eight  Fine  Engravings. 
Cloth,  $5.00;  sheep,  $6.00. 

The  following  are  the  points  of  excel- 
lence in  this  work : 

It  deals  only  with  matters  of  practical 
interest  to,  and  questions  that  are  likely 
to  arise  daily  in  the  work  of  the  practicing 
physician.     Its  scope  is  a  terse  yet  clear 
exposition    of    the    principles    governing 
modern  operative  surgery.     It  enters  into 
the  practical  details  of  all  the  varying  con- 
ditions of  the  application  of  the  antiseptic 
method  as  brought  about  by  emergencies. 
Every  important  prin- 
ciple   is    clearly   illus- 
trated by  citations  from 
actual   cases   occurring 
in    the   author's    prac- 
tice. 

It  is  not  intended 
to  take  the  place  of  any 
text-book  on  surgery, 
but  rather  to  supply  a 
need  which  exists  in 
every  work  on  the  sub- 
ject in  the  English  lan- 
guage, by  furnishing 
information  on  the  sub- 
ject of  Asepsis  and 
Antisepsis,  with  which 
It  is,  in  short,  a  supple- 


Fig.  147. — Necrotomy  of  tibia. 


Leg  placed  on  a  hard  cushion, 
from  the  right. 


Irric 


no  book  on  surgery  deals  to  an  extent  demanded  by  modern  methods 
ment  to  all  surgical  text-books. 

The  illustrations  are  typo-gra- 
vures,  made  from  photographic 
negatives  taken  from  life,  and  are 
marvels  of  beauty,  artistic  elegance, 
and  fidelity,  each  illustration  being 
a  faithful  representation,  by  the 
camera,  of  the  details  of  the  appli- 
cation of  .  all  important  antiseptic 
dressings  and  apparatus,  approach- 
ing nearer  to  an  actual  demonstra- 
tion than  has  ever  before  been  at- 
tempted to  be  done  in  any  medical 
work.     With  the  exception  of  a  few 


bacteriological  illustrations  taken  from  Koch, 
Rosenbach,  and  Bumm,  the  illustrations  are 
from  negatives  made  in  the  operating-room,  and 
are  of  a  character  now  for  the  first  time  em- 
ployed in  a  medical  work. 

The  work  has  been  adopted  by  the  Medical 
Department  of  the  United  States  Army. 


"This  work  of  three  hundred  and  twenty-five 
pages  occupies  a  field  which,  though  hinted  at  in 
other  treatises  on  surgery,  has  never  as  satisfac- 
torily been  presented,  and  as  such  will  be  welcomed 
by  the  entire  medical  fraternity.  .  .  .  Typograph- 
ically, the  volume  is  perfect,  and  no  physician, 
whether  he  has  made  surgery  a  matter  of  special 
investigation  or  not,  will  ever  regret  having  pur- 
chased this  work,  which  is  the  matured  thought  of 


--^y. 


Fig.  172. — Dressing  for  mammary  abscess,  or  empyema. 

a  careful  and  scholarly  medical  scientist." — Ameri- 
can Medical  Digest. 

"...  Just  such  books  as  this  are  needed  to  ex- 
pound the  principles  of  asepsis,  while  demonstrat- 
ing the  methods  by  which  it  may  be  attained.  .  .  . 
It  is  a  difficult  matter  to  find  anything  in  this 
magnificent  book  that  may  be  adversely  criticised." 
Pittsburg  Medical  Review. 


D.   APPLE  TON   &-   CO.'S  MEDICAL    WORKS. 


55 


"  Dr.  Gerster  has  written  a  valuable  and  inter- 
esting book ;  valuable  in  that  it  gives  the  details  of 
anti-parasitic  surgery  in  the  hands  of  an  adept  and 
an  enthusiastic  behever  in  it,  and  interesting  be- 
cause it  is  largely  a  record  of  personal  experience. 
The  profuseness  of  the  illustrations,  and  their 
beauty,  add  much  to  the  value  of  the  work." — 
Philadelphia  Medical  Times. 

"...  The  book  may  be  termed  a  treatise  on 
operative  surgical  physiology  and  pathology,  if 
there  be  no  contradiction  in  this  combination  of 
words.  Or,  it  may  be  said  that  the  book  is  a  series 
of  illustrative  sermons  on  the  text.  The  surgeoti's 
act  determines  the  fate  of  a  fresh  wound,  and  its 
infection  and  suppuration  are  due  to  his  technical 
faults  of  omission  and  com7nission.  .  .  ." — jour- 
nal of  the  America7i  Medical  Association. 


"  If  ever  there  was  a  timely  book  written  this  is 
it.  .  .  .  We  need  say  nothing  more  of  this  volume 
than  we  have  already  said  to  assure  our  readers  that 
it  is  one  of  remarkable  value.  If  it  has  its  equal 
anywhere  we  are  not  aware  of  it.  If  anything  is 
needed  to  make  the  author's  reputation  this  book 
will  do  it,  as  it  will  most  surely  find  its  way  into 
every  town,  village,  and  hamlet  in  our  broad  land. 
.   .   ." — North  Carolitia  Medical  Journal. 

"This  is  as  beautiful  a  specimen  of  the  book- 
maker's art  as  we  have  seen.  .  .  .  The  beauty  and 
abundance  of  the  illustrations — which  are  photo- 
graphs taken  during  operation — add  greatly  to  the 
practical  value  of  the  work.  In  a  word,  it  is  a 
book  which  every  physician  who  does  any  surgical 
work  ought  to  have." — Buffalo  Medical atid Surgi- 
cal fournal. 


A  TEXT-BOOK    OF    DISEASES    OF   THE    SKIN.      By 

John   V.    Shoemaker,   A.  M.,  M.  D.,   Professor   of    Dermatology   in   the 
Medico-Chirurgical  College  of  Philadelphia. 

8vo.      With  Six  Chromo-Lithographs  and  numerous  Engravings. 
Cloth,  $5.00;    sheep,  $6.00. 


"  .  .  .  It  is  a  treatise  on  the  skin  which  we  can 
recommend  to  every  physician  as  a  work  of  refer- 
ence, and  in  which  "he  will  find  the  latest  views  on 
pathology  and  treatment.  At  the  end  of  the  work 
are  a  number  of  formulae,  which  will  prove  very 
valuable  as  a  reference.  It  is  certainly  a  very  com- 
plete book." — Canada  Lancet. 

"  This  is  an  entirely  new  work  upon  diseases  of 
the  skin,  by  one  who  evidently  has  had  very  large 
observation  and  experience  in  those  affections. 
.    .    .    Students  and    physicians  will  find    it  well 


adapted  to  their  wants.  A  proper  study  of  it  will 
give  them  a  very  satisfactory  knowledge  of  skin 
affections." — Cincinnati  Medical  News. 

"...  Dr.  Shoemaker's  excellent  work  will  be 
especially  acceptable  to  the  profession  as  being  free 
from  cumbrous  technicality,  and  as  having  been 
prepared  to  interest  and  instruct  the  practitioner, 
and  not  to  embarrass  him  with  burdensome  details 
that  might  make  the  study  and  the  subject  a  tax 
rather  than  a  pleasure."  —  College  and  Clinical 
Record. 


ELEMENTS    OF   THERAPEUTICS    AND    PRACTICE 

ACCORDING  TO  THE  DOSIMETRIC  SYSTEM.    By  Dr.  D'Oliveira 


Castro. 


8vo,  488  pp.    Cloth,  $4.00. 


THE  NEW  YORK  MEDICAL  JOURNAL  VISITING- 
LIST  AND  COMPLETE  POCKET  ACCOUNT-BOOK.  Prepared  by 
Charles  H.  Shears,  A.  M.,  M.  D. 

Price,  $1.25. 

This  List  is  based  upon  an  entirely  new  plan,  the  result  of  an  effort  to  do  away  v/ith 
the  defective  method  of  keeping  accounts  found  in  all  visiting-lists  hitherto  published. 
Each  page  is  arranged  for  the  accounts  of  three  patients,  to  the  number  of  thirty-one 
visits  each,  which  may  have  been  made  during  a  current  month  or  may  extend  over  a 
number  of  months,  according  to  the  frequency  of  the  visits.  With  the  simple  system 
here  inaugurated,  the  practitioner  can  at  a  glance,  and  without  the  trouble  of  tracing 
the  narrow  columns  found  in  the  ordinary  lists,  ascertain  the  condition  of  the  account 
of  any  patient ;  when,  and  how  many  visits  have  been  made ;  what  has  been  paid,  and 
how  much  is  still  due.  It  is  provided  with  an  Index,  and  is,  without  doubt,  the  most 
perfect  Visiting-List  e^jer  offered  to  the  profession,  as  it  possesses  all  the  advantages 
without  the  obiectionable  features  found  in  all  others.  Its  USE  can  be  BEGUN  AT 
ANY  TIME, 


INDEX 


PiGK 

Air,  Essays  on  the  Floating  Matter  of  the 25 

Anaesthesia,  Local,  in  General  Medicine  and  Surgery.  47 

Anatomy,  of  the  Nervous  System 26 

i'hysiology  and  Hygiene,  I'he  Essentials  of 42 

The  Comparative,  of  the  Domesticated  Animals.  10 

i'he,  of  Invertebrated  Animals 20 

The,  of  Vertebrated  Animals 15 

Aorta,  Diseases  of  the  Heart  and  Thoracic 42 

Bacteriological  Investigation,  The  Methods  of 19 

Barker.     On  Sea-Sickness i 

The  Puerperal  Diseases i 

Bartholow.     A  i' realise  on  the  Practice  of  Medicine. .  4 
On  the  .Antagonism  between  Medicines 5 

I  realise  on  Materia  Medica  and  Therapeutics  . .  3 

Bastian.     Paralyses:   Cerebral,  Bulbar,  and  Spinal...  37 

Paralysis  from  Brain  Disease i 

The  Brain  as  an  Organ  of  Mind 3 

Bennet.     On  th?  i'reatment  of  Pulmonary  Consump- 
tion...   5 

Winter  and  Spring  on  the  Shores  of  the  Medi- 
terranean   5 

Bile,  Jaundice,  and  Bilious  Diseases,  On  the 17 

Billings.      The   Relation  of  Animal   Diseases  to   the 

Public  Health 43 

Billroth.     General  Surgical  Pathology  and  Therapeu- 
tics  6 

Body  and  Mind 22 

B  mes,  A  Treatise  on  Diseases  of  the 24 

Brain  Disease,  Paralysis  from i 

Exhaustion,  A  Treatise  on 41 

The,  and  its  Functions 34 

The,  as  an  Organ  of  Mind 3 

Bramwell.     Diseases  of  the  Heart  and  Thoracic  Aorta  42 
Breath,   The,  and  the  Diseases  which  give  it  a  Fetid 

Odor 17 

Bryant.     A  Manual  of  Operative  Surgery 49 

Buck.     Contributions  to  Reparative  Surgery 12 

Carpenter.     Principles  of  Mental  Physiology 2 

Carter.     Elements  of  Practical  iNIedicine 37 

Castro.      Elements  of  Therapeutics  and  Practice  ac- 
cording to  the  Dosimetric  System 55 

Chauveau.      The  Comparative  Anatomy  of  the    Do- 
mesticated Animals 10 

Chemical  Technology,  A  Hand-book  of 31 

Che.Tiistry,  Inorganic 33 

Organic 33 

Short  Text-book  of  Organic 2 

The,  of  Common  Life 12 

Children,  A  Pr.^ctical  Treatise  on  Disea.ses  of 36 

Children's  Diseases,  Compendium  of. 28 

Club-Foot,  A  Practical  Manual  on  the  Treatment  of. .  28 

Combe.      I  he  Management  of  Infancy i 

Consumption,  On  the  Treatment  of  Pulmonary 5 

Corfield.     On  Health 2 

Corning.     A  Treatise  on  Brain-Exhaustion 41 

Local  Anaesthesia  in  General  Medicine  and  Sur- 
gery   47 

Davis.     Conservative  Surgery 11 

Deformities,  A  Treatise  on  Oral 16 

Dermatology,  A  Manual  of 45 

Diseases,  The.  of  Sedentary  and  Advanced  Life 46 

Down.     Health  Primers 19 

Ear,  The  Diagnosis  and  Treatment  of  Diseases  of  the.  46 

Education,  Physical 23 

Electricity  in  Medicine,  The  Uses  of 50 

Elliot.     Obstetric  Clinic 7 

Emergencies,  and  How  to  Treat  them 14 

EvetsJcy.     The  Physiological  and  Therapeutical  Ac- 
tion of  Ergot 6 

Eye,  A  Hand-book  of  the  Diseases  of  the 42 

Flint.     Manual  of  Chemical  Examination  of  the  Urine 

in  Disease 7 

Medical  Ethics  and  Etiquette 44 

Medicine  of  the  F'utiirc 47 

On  the  Physiological   Effects  of  Severe  and  Pro- 
tracted Muscular  Exercise 7 

Text-book  of  Human  Physiology 8 

The  Physiology  of  Man 9 


Flint.     The  Source  of  Muscular  Power 7 

Foods 31 

Fothergill.    The  Diseases  of  Sedentary  and  Advanced 

Life 46 

Fournier.     Syphilis  and  Marriage 9 

Erey.     The  Histology  and  Histo-Chemistry  of  Man. .  11 

Friedlaender.     The  Use  of  the  Microscope 44 

Gamgee.     Yellow  Fever,  a  Nautical  Disease 11 

Garmany.     Operative  Surgery  on  the  Cadaver 53 

Genito-Urinary  Organs,  Surgical  Diseases  of  the  ....  31 

Gerster.  Rules  of  Aseptic  and  Antiseptic  Surgery. .  .  54 
Gross.     A  Practical  Treatise  on  Tumors  of  the  Alam- 

mary  Gland 13 

Gutmann.     Watering-Places  and  Mineral  Springs  of 

Germany,  Austria,  and  Switzerland 28 

Gynaecological    Transactions.      Vols.  VIII,    IX,    X, 

and  XI 50 

Hamilton.     Clinical  Electro-Therapeutics 20 

Hammoiid.     A  Treatise  011  Insanity 38 

A  Treatise  on  the  Diseases  of  the  Nervous  Sys- 
tem   14 

Clinical  Lectures  on   Diseases  of  the   Nervous 

System 15 

Harvey.      First  Lines  of  Therapeutics 17 

Health 2,  29 

A  Ministry  of,  etc 27 

And  How  to  Promote  it 22 

Primers 19 

Heart  and  Thoracic  Aorta,  Diseases  of  the 42 

Histology  and  Histo-Chemistry,  The,  of  Man 11 

Hoffman  and  Ultzmann.     Analysis  of  the  Urine.  . .    .  20 

Hospital  Reports.     Bellevue  and  Charity 30 

Hospitals 33 

Howe.     Emergencies,  and  How  to  Treat  them. ......  14 

The   Breath,  and  the  Diseases  which  give  it  a 

Fetid  Odor , 17 

Hueppe.  The  Methods  of  Bacteriological  Investiga- 
tion   19 

Huxley.     The  Anatomy  of  Invertebrated  Animals. .  .  20 

The  Anatomy  of  Vertebrated  Animals 15 

Hygiene,  Physiologj-,  and  Anatomy,  The  Essentials 

of 42 

Infancy,  The  Management  of i 

In-Knee,  Medical  and  Surgical  Aspects  of 34 

Insanity,  A  Treatise  on 38 

Jaccoud.  The  Curability  and  Treatment  of  Pulmo- 
nary Phthisis 44 

Johnson.     The  Chemistry  of  Common  Life 12 

Joints,  Lectures  on  Orthopedic  Surgery  and  Diseases 

of  the 29 

Jones.     Practical  Manual  of  Diseases  of  Women  and 

Uterine  Therapeutics 41 

Journal,  The  New  York  Medical 36 

Keyes.  A  Practical  Treatise  on  the  Surgical  Dis- 
eases of  the  Genito-Urinary  Organs 32 

■  The  Tonic  Treatment  of  Syphilis 12 

Kingsley.     A  Treatise  on  Oral  Deformities 16 

Iiegg.  On  the  Bile,  Jaundice,  and  Biliotis  Diseases  .  17 
Letterman.     Medical  Recollections  of  the  Army  of  the 

Potomac 22 

Life,  Diseases  of  Modern 28 

The  Diseases  of  Sedentary  and  Advanced 46 

Little.     Mediciil  and  Surcic.nl  Aspects  of  In-Knee. .. .  34 

Loring.     A  Text-bonk  of  Ophthalmoscopy 46 

f.usk.     The  .Science  and  Art  of  Midwifery 18 

Luys.     The  Brain  and  its  Functions 34 

Mammary  Gland,  Tumors  of  the 13 

Markoe.     A  J'reatise  on  Diseases  of  the  Bones 24 

Materia  Medica  and  Therapeutics,  Elements  of 24 

Treatise  on 3 

Matter,  the  Floating,  of  the  Air,  Essays  on 25 

Maudsley.      Body  and  Mind 22 

Responsibility  in  Mental  Diseases 22 

The  Pathology  of  Mind 21 

The  Physiology  of  the  Mind 23 

McSherry.     Health,  and  How  to  Promote  it 22 


